A study on the boundary value of hemoglobin concentration for screening iron deficiency anemia in pregnant women

To evaluate whether a pregnant woman is in anemia or there exist the needs to replenish iron is usually based on the measurement of hemoglobin (HB) concentration, because the evaluation of iron nutritional status has not yet been used widely in our country. Blood specimens were collected from 258 pregnant women, and concentrations of Hb, serum ferritin (SF) and free erythrocyte protoporphyrin (FEP) were determined to find out a reasonably boundary value of Hb concentration from the two different ones set by our country and WHO, respectively, and the one averaged the former two, i.e, 100g/L, 110g/L and 105g/L. False positivity and false negativity in diagnosis of iron deficiency anemia (IDA) for pregnant women were evaluated based on the measurement of SF and FEP concentrations as gold standards. Results showed that the optimal Hb concentration for preliminary diagnosis of IDA was 105g/L with maximizing Yorden index.     

Pernicious anaemia patients should be screened for iron deficiency during follow up

AIMS: To investigate if patients with pernicious anaemia (PA) are prone to develop iron deficiency and if there is a difference for this manifestation between younger and older age groups. METHODS: Ninety-five patients with pernicious anaemia were evaluated for body iron status at the time of diagnosis and during follow up. Patients were also divided into two groups; younger than 60 (53 patients) and older than 60 (42 patients) years of age. Groups were compared for iron deficiency both at the time of diagnosis and at the end of follow up period. RESULTS: Iron deficiency was a common finding in patients with pernicious anaemia. This deficiency state was more common in the elderly. During B12 therapy, iron deficiency increased in all groups, but the increased rate of iron deficiency was more prominent in the elderly patients. CONCLUSION: Pernicious anaemia is an atrophic gastropathy in which gastric parietal cells no longer produce hydrochloric acid. These patients with achlorhydria demonstrate impaired absorption of iron. On the other hand, with ageing, gastric acidity is already diminished. Iron deficiency commonly accompanies patients with pernicious anaemia and this is more pronounced in the elderly group. We suggest that all patients with pernicious anaemia, especially the elderly, should be screened for iron deficiency both at the beginning and during the follow up.     

The relationship of haemoglobin to serum erythropoietin concentrations in the anaemia of rheumatoid arthritis: the effect of oral prednisolone

Previous studies of the erythropoietin response to anaemia in RA have yielded conflicting findings. Some have found the response to be impaired and others have found a normal response. We have compared erythropoietin (EPO) levels measured by radioimmunoassay, in 54 anaemic rheumatoid patients and 55 patients with iron deficiency anaemia but no inflammatory disease. The erythropoietin response in the rheumatoid patients was impaired compared with the control group (P < 0.025) but only seven rheumatoid patients showed a response which fell below the 95% confidence intervals predicted for the control group. Rheumatoid patients who fell within the highest quartile for serum ferritin concentrations (i.e. those most likely to have anaemia of chronic disease) had significantly lower EPO levels compared with the control group (P < 0.01). EPO levels in rheumatoid patients within the lowest quartile for ferritin (i.e. those with iron deficiency anaemia) were not significantly different from the control group (P = 0.670). The difference in EPO response between the RA patients in the upper and lower quartile for ferritin approached but did not achieve significance (P = 0.056). In a second study 15 anaemic RA patients were given a 5-day course of oral prednisolone 1.5 mgkg-1. Hemoglobin did not rise significantly until day 4 but EPO levels fell by day 1 (P < 0.005) and remained lower than pretreatment values throughout the study. Thus, in RA patients, anaemia of chronic disease is associated with inappropriately low EPO concentrations but this does not appear to be the major cause of the anaemia and Hb response to prednisolone does not depend upon an increase in EPO concentration.     

Nursing informatics--what on earth?

AIM AND BACKGROUND: Two forms of hypochromic microcytic anaemia i.e. iron deficiency and beta-thalassaemia trait are common in our society. This study reports the prevalence of iron deficiency anaemia and beta-thalassaemia trait and predictive value of MCV/RBC count ratio to discriminate between two. METHODS: Venous blood was taken from 299 students of Karachi Medical & Dental College and Ziauddin Medical University in Na2 EDTA and analyzed by semi-automated Sysmex K-1000 haematology analyzer. MCV/RBC count ratio was used to discriminate between iron deficiency and beta-thalassaemia trait and > 14% was marked as iron deficiency. Hb electrophoresis was used as gold standard test for confirmation. Serum iron and TIBC was performed to confirm iron deficiency anaemia. RESULTS: Iron deficiency was found in 9% while beta-thalassaemia was seen in 3% students. MCV/RBC count ratio showed a positive predictive value of 91%. CONCLUSIONS: In areas where iron deficiency anaemia and beta-thalassaemia trait are common, MCV/RBC count ratio can be used to screen out beta-thalassaemia trait.     

Negative mammograms in symptomatic patients with breast cancer

BACKGROUND: Highly bioavailable dietary iron is needed to ensure optimal iron status in infants during weaning. The purpose of the current study was to examine the effect of increased meat intake on hemoglobin concentration (Hb), serum ferritin (SF), and serum transferrin receptors (TfR) in late infancy. METHODS: Forty-one healthy, term, partially breast-fed 8-month-old infants were randomized into two groups: a low-meat group (LMG), in which infants received a diet with a mean meat content of 10 g/day and a high-meat group (HMG), in which infants received a diet with a mean meat content of 27 g/day. The intervention lasted for 2 months, and blood samples were drawn on the first and the last days of the intervention. RESULTS: At the beginning of the intervention, no significant differences were found in Hb, SF, TfR values between the two groups. After the intervention, there was a significant (p = 0.008) difference in the change in hemoglobin (delta Hb) concentration. In the LMG delta Hb was -4.9 g/l (range, -12.9-5.6 g/l) and in the HMG -0.6 g/l (range, -12.1-7.3 g/l). There was no significant difference in change in SF or TfR concentrations between the LMG and the HMG. The intake of iron from meat (mean; range) was significantly higher (p = 0.0001) in the HMG (0.4 mg/day; 0.02-0.7 mg/day) than in the LMG (0.1 mg/day; 0.03-0.5 mg/day). However, there was no significant difference in total iron intake between the HMG (3.1 mg/day; 0.4-6.2 mg/day) and the LMG (3.4 mg/day; 1.4-6.1 mg/day). CONCLUSION: The results suggest that an increase in meat intake can prevent a decrease in Hb in late infancy, probably by enhancing iron absorption. However, there was no effect on iron stores or on cellular iron deficiency, evaluated by SF and TfR levels, respectively.     

Treatment of anemia in patients with chronic renal insufficiency with recombinant human erythropoietin

The discovery of recombinant human erythropoietin has enabled treatment of anaemia in patients whose anaemia was primarily caused by the lack of erythropoietin. This agent was most widely used in the treatment of anaemia in chronic renal failure patients. Non-regulated hypertension is considered to be the only absolute contraindication for recombinant human erythropoietin application, but thrombocytosis, predisposition to thromboses of arterio-venous fistulae, and convulsions are regarded as relative contraindications. Recombinant human erythropoietin may be administered intravenously, but the subcutaneous route is considered more rational. The treatment is initiated by low doses with gradual dose increase, what enables gradual anaemia correction and prevents the appearance of adverse effects. Haemoglobin level of around 100 g/l is considered the target haemoglobin level. The majority of patients respond well to treatment by human recombinant erythropoietin and the absence of anaemia improvement may be the result of iron deficiency, occult haemorrhages, chronic infection, inadequate dialysis, secondary hyperparathyroidism, aluminium intoxication. Anaemia improvement during the treatment with recombinant erythropoietin leads to the improvement of function of most organs and the quality of life in general as well as avoidance of blood transfusions and their adverse effects. The most frequent adverse effect of recombinant erythropoietin is the development of iron deficiency or hypertension aggravation.     

The role of serum transferrin receptor in the diagnosis of iron deficiency

BACKGROUND AND OBJECTIVE: Iron deficiency anemia (IDA) is often associated with inflammatory disorders. The most conventional parameters of iron metabolism are therefore affected, making the evaluation of iron status difficult. Serum transferrin receptor (sTfR) levels are raised in iron deficiency but are not influenced by inflammatory changes. The aim of this study was to investigate the role of sTfR in differentiating IDA with inflammatory features. DESIGN AND METHODS: A diagnostic study of sTfR measured by immunoassay was carried out in IDA and anemia of chronic disorders (ACD). The cut-off points of sTfR and the ratio of sTfR/serum ferritin, which were obtained after comparing IDA and ACD, were applied to a group of 64 patients with mixed iron patterns (MIX) (16 with ACD and 48 with IDA). RESULTS: The best cut-off point of sTfR between IDA and ACD was 4.7 mg/L. Applying this cut-off to the MIX group, an efficiency of 87% was obtained (sensitivity 92% and specificity 81%). This level of sTfR correctly classified 53 out of 64 cases of the MIX group (83%). Using the ratio of sTfRx 100/serum ferritin, the best cut-off point was 8 (efficiency 100%), which correctly classified 62 out of 64 cases of the MIX group (97%). INTERPRETATION AND CONCLUSIONS: This study demonstrates that sTfR in conjunction with other iron parameters is very useful in iron deficiency evaluation, especially in hospital practice. Iron treatment should be considered in patients with mixed patterns of iron status, in which the diagnosis of IDA versus ACD is difficult, when the levels of sTfR exceed the cut-off point.     

Anaemia in pregnant women in eastern Caprivi, Namibia

OBJECTIVE: To describe the prevalence, character and possible aetiology of anaemia in the study region. DESIGN: A cross-sectional study involving a lifestyle and dietary questionnaire, a clinical examination and an analysis of blood and stool samples. SETTING: Katima Mulilo antenatal clinic, East Caprivi, Namibia. SUBJECTS: 171 pregnant women attending the clinic in September 1995. MAIN OUTCOME MEASURES: Effects on haemoglobin concentration of age, trimester, parity, residential area, sociodemographic factors, malaria, parasites, geophagy, diet, cooking pot used, vitamin and mineral supplementation and malaria prophylaxis. RESULTS: 41.5% of the women were found to be anaemic (haemoglobin < 11 g/dl) and there was a significant risk of their being iron-deficient (P = 0.01). Three maternal characteristics were found to have a significant effect on a woman's risk of anaemia: urban residence (P < 0.05), geophagy (P < 0.01) and the taking of prophylactic chloroquine (P < 0.05). CONCLUSION: Mild anaemia affects a large proportion of the pregnant women in East Caprivi; severe anaemia (< 7 g/dl) is not common. The picture is predominantly one of iron deficiency, possibly complicated by concomitant folate deficiency. There is no single easily identifiable cause of this anaemia; it appears to have a multifactorial aetiology. Further studies on the effect of the current malaria prophylaxis programme are warranted.     

Predicting the time course of haemoglobin in children treated with erythropoietin for renal anaemia

AIMS: To establish a pharmacodynamic model that allows one to predict the haemoglobin (Hb) response to EPO in children as a function of dose and time, and to derive recommendations for initial dosing and subsequent dose adjustment. METHODS: Haemoglobin was monitored in eight children aged 8-15 years with anaemia due to renal failure during treatment with EPO. All patients were free of conditions known to impair the response to EPO. Pretreatment Hb was 4.9-9.0 g dl(-1). The drug was administered once weekly by subcutaneous injection; doses ranged from 1700 to 6800 U week (-1). Hb was monitored for 4-38 months. The Hb-time data were analysed by applying a population pharmacodynamic model proposed for EPO in adult haemodialysis patients. Internal model validation was carried out by using a bootstrap procedure. RESULTS: The increase of Hb during treatment with EPO was linear until steady state was reached after 103+/-33 days (mean +/- interindividual s.d.). The weekly gain in Hb from the onset of therapy to steady state was 0.0805+/-0.026 g dl(-1) (mean +/- interindividual s.d.) for every 1000 U EPO week (-1); it did not exhibit a dependence on body weight. Estimated mean prediction errors are +/-1.53 g dl(-1) for predictions that are based on the mean population parameters and +/-0.83 g dl(-1) for predictions that take into account the complete individual Hb-time data up to and including steady state. CONCLUSIONS: The model describes the time course of the Hb response to EPO in children with renal anaemia. The required weekly EPO dose should initially be calculated from the individual pretreatment Hb and the desired Hb at steady state by using the mean population estimates of the weekly gain in Hb per dose unit before steady state (beta) and the time needed to reach steady state (tau). A reduction of the initial dose according to body weight is not justified by the available evidence. beta should be re-estimated individually after 6 weeks of treatment and dose should be adjusted accordingly. A final dose adjustment should be made when steady state has been reached based on individual estimates of beta and tau.     

Clinicopathologic characteristics of replication error-positive gastric carcinoma

OBJECTIVES: To determine the incidence of skull fracture (SF) and intracranial injury (ICA) among children younger than 2 years evaluated in a pediatric emergency department for head trauma; whether historical features and/or physical findings are predictive of injury type; and whether clinical criteria could allow a selective approach to radiographic imaging. DESIGN: Retrospective medical record review. SETTING: Tertiary pediatric emergency department. PATIENTS: Case series of 278 children aged younger than 24 months evaluated for head injury. MAIN OUTCOME MEASURES: Presence of SF and/or ICA. RESULTS: Diagnoses at discharge included 227 minor head injuries, 39 isolated SF, 9 ICA with SF, and 3 isolated ICA. Children younger than 12 months had the highest incidence of SF/ICA (29%) vs 4% for children aged 13 to 24 months (P<.001). Seven percent of complications from SF/ICA resulted from falls 3 ft (0.9 m) or less [corrected]. Incidence of behavioral change, loss of consciousness, emesis, and seizures did not differ significantly between those with minor head injuries and those with SF/ICA. Scalp abnormalities were more common in children with SF/ICA (P<.001). Sixty-two percent of children with isolated SF and 58% of children with ICA had no history of loss of consciousness, emesis, seizure, or behavioral change. Ninety-two percent of children with isolated SF and 75% of children with ICA had normal levels of consciousness and nonfocal neurologic examinations at diagnosis. Among children who fell 3 ft or less (0.9 m) [corrected] and had no loss of consciousness, emesis, seizure, behavioral change, or scalp abnormality, none of 31 (95% confidence interval [CI], 0-0.10) children younger than 24 months and none of 20 (95% CI, 0-0.15) children younger than 12 months had SF/ICA. CONCLUSIONS: Both SF and ICA are common in children younger than 2 years evaluated for head trauma. Children younger than 12 months are at highest risk. Injuries resulted from relatively minor falls and occurred in alert, neurologically normal children. Clinical signs and symptoms were insensitive predictors of SF/ICA; however, a grouping of features (fall < or = 3 ft [0.9 m], no history of neurologic symptoms, and normal scalp physical examination results) identified a subset of children at low risk for complications.     

Percentage hypochromic red cells and the response to intravenous iron therapy in anaemic haemodialysis patients

INTRODUCTION: Iron deficiency is commonly encountered in haemodialysis (HD) patients and may be overcome by i.v. iron therapy. We have examined the percentage hypochromic red cells (%HRC) for predicting response to i.v. iron in subjects with a low serum ferritin. METHODS: Prospective study of i.v. iron saccharate (trivalent iron 200 mg/week for 8 weeks) in anaemic (Hb < 10 g/dl) HD patients with serum ferritin < 100 microg/l despite oral iron therapy. Response to i.v. iron was assessed by comparing Hb at 0 and 8 weeks according to %HRC at baseline (0-3%, 4-9%, > or = 10%). Results are mean+/-1 SD. RESULTS: For all subjects (n=82), Hb and ferritin increased between 0 and 8 weeks (8.9+/-1.0 to 10.1+/-1.4, P<0.0001; 55+/-24 to 288+/-126, P<0.0001). Patients were stratified into three groups according to %HRC at baseline (0-3%, 4-9%, > or = 10%). Hb increased significantly in all three groups. The mean increase in Hb was greater (0-3%, 0.6+/-1.2; 4-9%, 1.2+/-1.0; > or = 10%, 1.6+/-1.4; P=0.02) and the proportion of patients showing a > or = 1 g/dl increase in Hb was greater (0-3%, 27%; 4-9%, 57%; > or = 10%, 67%; P=0.02) in those with the largest %HRC pre-treatment. CONCLUSION: Intravenous iron therapy is effective in improving Hb in anaemic HD patients with a low ferritin. However, the magnitude of this response and the proportion of patients responding is related to the percentage hypochromic red cells prior to treatment.     

Iron deficiency and anaemia in a longitudinal study of New Zealanders at ages 11 and 21 years

AIMS: To determine iron status in a longitudinal study of New Zealanders, the Dunedin Multidisciplinary Health and Development Study (DMHDS), at ages 11 (1983-4) and 21 (1993-4). METHODS: Red cell variables were measured in 553 (298 males, 255 females) and 784 (413 males, 371 females) members of the DMHDS at ages 11 and 21, respectively. A total of 456 (259 males, 197 females) members were tested at both ages. Serum ferritin was measured at age 21 only. RESULTS: The prevalence of anaemia in females (haemoglobin < 120 g/L) increased from 3.1% at age 11 to 5.8% at age 21 (pregnant women excluded). There was a significant association between low haemoglobin at age 11 and low haemoglobin at age 21. In males, prevalence of anaemia decreased from 2.3% at age 11 to 0.97% (haemoglobin < 130 g/L) at age 21. The prevalence of iron deficiency (ferritin < 12 ng/mL) at age 21 was 0.24% in men and 6.7% in women. The prevalence of iron deficiency with anaemia at age 21 was zero in men and 2.2% in women. CONCLUSIONS: The prevalences of anaemia and iron deficiency in the DMHDS appear to be low by comparison with similar populations in other countries. Anaemia appears to be a stable trait in young women and screening may be useful for its early detection.     

Is serum transferrin receptor useful for detecting iron-deficiency in anaemic patients with chronic inflammatory diseases?

We investigated whether determination of serum transferrin receptor (TfR) is useful for detecting iron-deficiency in patients with chronic inflammatory diseases and for differentiating between iron-deficiency anaemia and anaemia of inflammation. Using an immunofluorometric assay, serum TfR was measured in 34 anaemic patients. Of these patients, 23 had a chronic rheumatic disease, 13 with both inflammation and iron-deficiency and 10 with anaemia of inflammation only; the other 11 patients had iron-deficiency anaemia and no evidence of inflammation. Serum TfR concentrations were lower in patients with anaemia of inflammation (2.6 +/- 0.2 mg/l, mean +/- S.E.M.) than in patients with iron-deficiency anaemia (6.7 +/- 1.1 mg/l, P < 0.01) or those with both inflammation and iron deficiency (5.8 +/- 1.0 mg/l, P < 0.01). Among patients with inflammatory disease, correlations between TfR and ferritin concentrations (r = -0.62, P < 0.05) and TfR and erythropoietin concentrations (r = 0.69, P < 0.001) were observed in iron-deficient subjects only. TfR, though not superior to serum ferritin, can help to distinguish between anaemia of inflammation and iron-deficiency anaemia and to identify iron-deficiency in subjects with chronic inflammation.     

Red blood cell precursor mass as an independent determinant of serum erythropoietin level

Serum erythropoietin (sEpo) concentration is primarily related to the rate of renal production and, under the stimulus of hypoxia, increases exponentially as hemoglobin (Hb) decreases. Additional factors, however, appear to influence sEpo, and in this work, we performed studies to evaluate the role of the red blood cell precursor mass. We first compared the relationship of sEpo with Hb in patients with low versus high erythroid activity. The first group included 27 patients with erythroid aplasia or hypoplasia having serum transferrin receptor (sTfR) levels < 3 mg/L (erythroid activity < 0.6 times normal), while the second one included 28 patients with beta-thalassemia intermedia having sTfR levels > 10 mg/L (erythroid activity > 2 times normal). There was no difference between the two groups with respect to Hb (8.3 +/- 1.6 v 8.0 +/- 1.3 g/dL, P > .05), but sEpo levels were notably higher in patients with low erythroid activity (1,601 +/- 1,542 v 235 +/- 143 mU/mL, P < . 001). In fact, multivariate analysis of variance (ANOVA) showed that, at any given Hb level, sEpo was higher in patients with low erythroid activity (P < .0001). Twenty patients undergoing allogeneic or autologous bone marrow transplantation (BMT) were then investigated. A marked increase in sEpo was seen in all cases at the time of marrow aplasia, disproportionately high when compared with the small decrease in Hb level. Sequential studies were also performed in five patients with iron deficiency anemia undergoing intravenous (IV) iron therapy. Within 24 to 72 hours after starting iron treatment, marked decreases in sEpo (up to one log magnitude) were found before any change in Hb level. Similar observations were made in patients with megaloblastic anemia and in a case of pure red blood cell aplasia. These findings point to an inverse relationship between red blood cell precursor mass and sEpo: at any given Hb level, the higher the number of red blood cell precursors, the lower the sEpo concentration. The most likely explanation for this is that sEpo levels are regulated not only by the rate of renal production, but also by the rate of utilization by erythroid cells.     

Transfusion and recombinant human erythropoietin requirements differ between dialysis modalities

BACKGROUND: Before the routine use of recombinant human erythropoietin (rHuEpo), patients dialysed by peritoneal dialysis (PD) received fewer blood transfusions than patients on haemodialysis (HD). We compared transfusion practices in these groups now that the use of rHuEpo has become standard, while controlling for variables known to influence anaemia of end-stage renal disease (ESRD). Maintenance rHuEpo doses were also compared. METHODS: Data were examined for 157 HD and 126 PD patients during a 2-year period. Potential confounders included age, gender, albumin, iron deficiency, parathyroid hormone (PTH), underlying renal disease, comorbid illness, renal transplant, dialysis adequacy and duration. An intent-to-treat analysis was used, with sensitivity analyses to account for change in treatment and transplant. RESULTS: Mean haemoglobin (Hb) was not different (10.47 g/dl for HD, 10.71 g/dl for PD; P = 0.45). Mean monthly transfusion rate was higher for HD (0.47 units per month vs 0.19; P < 0.01). More HD patients received at least one transfusion (52.9 vs 40.9%; P < 0.01). The maintenance rHuEpo dose was higher for HD (7370 U/week vs 5790 U/week; P = 0.01). The only factors associated with risk of being transfused were dialysis duration and mode of dialysis (less risk for PD, odds-ratio 0.57; 95% confidence interval 0.35-0.92). CONCLUSIONS: Despite the routine use of rHuEpo, HD patients received more blood and rHuEpo than PD patients to achieve the same Hb. No patient factors were identified to account for this difference. The use of fewer transfusions and less rHuEpo in PD represents an advantage over HD in terms of both cost and safety.     

Familial idiopathic atrial fibrillation with bradyarrhythmia

OBJECTIVE: To determine whether the maternal haemoglobin and iron stores of non-anaemic mothers (haemoglobin > or = 10 g/dl) who developed postpartum anaemia were lower compared to mothers who did not develop postpartum anaemia. STUDY DESIGN: A prospective study was conducted in a teaching hospital on 467 low-risk mothers recruited from the antenatal clinic over a 3-month period, who were given only low dose iron supplement and delivered in the same hospital. Blood was drawn at 28-30 weeks for the measurement of haemoglobin, mean cell volume, serum ferritin, serum iron and total iron binding capacity. These results were compared between mothers with a postpartum day 3 haemoglobin of > or = 10 g/dl and those < 10 g/dl. Statistical analysis was performed with parametric and non-parametric methods as appropriate. RESULTS: Mothers with postpartum anaemia had a higher incidence of postpartum haemorrhage (19.6% vs. 3.9%, P < 0.001) as well as heavier mean intrapartum blood loss (444 ml vs. 304 ml, P < 0.001), but there was no difference in the haemoglobin, mean cell volume, serum ferritin, serum iron and total iron binding capacity. CONCLUSIONS: In mothers without antenatal anaemia, the development of postpartum anaemia is not related to the maternal iron status in the third trimester.     

Chicken extract stimulates haemoglobin restoration in iron deficient rats

Chicken essence is widely used as a traditional remedy for several ailments including anaemia. To test this claim for objective evidence, a series of experiments was carried out in anaemic rats by supplementing iron deficient diets with either liquid or lyophilised essence, which contains mainly protein and peptides (83 mg/ml) and free amino acids (3.1 mg/ml), very little iron (1 microgram/ml), and no fat. Haemoglobin returned to normal significantly more rapidly in rats supplemented with ad libitum liquid BEC over a period of up to 27 days compared with controls fed only water in addition to the ad libitum iron deficient diet. Haemoglobin was also significantly increased after 1 week in animals fed ad libitum diets supplemented with lyophilised chicken essence than with controls fed the unsupplemented diet. The effect was greater with supplementation at the level of 0.2% than at 1% lyophilised essence. The results indicate that the effects were mediated by increased appetite and by enhanced availability of food iron. These studies provide objective evidence for the traditional belief that chicken essence remedies anaemia.     

Anaemia in malaria control: a practical approach

Mortality from malarial anaemia and malarial infection in those who are already anaemic yet have some degree of compensation is now beginning to receive the attention it deserves. It is of particular concern in Africa and especially in young children and pregnant women. The asymptomatic parasitaemia remaining after poor response to full antimalarial treatment may lead to life-threatening anaemia; as drug-resistant strains of the malarial parasite proliferate this is becoming increasingly important. It is now possible to estimate haemoglobin levels, simply, cheaply, easily and safely, using a haemoglobin colour scale which is being developed by the World Health Organization. The potential and practical value of this scale in malaria-control programmes was demonstrated in a small, preliminary trial in 1995. Estimation of anaemia should become an additional parameter in the traditional malariometric survey. Haemoglobin concentrations should also be taken into consideration in the management of malaria patients at the primary-care level, particularly in deciding whether a patient should be referred to an appropriate treatment centre. The accurate prediction of clinical outcome of malaria and anaemia, and indication of the appropriate action (determined by a case-based reasoning device) should be possible in the near future.     

Role of small bowel biopsy in the endoscopic evaluation of adults with iron deficiency anemia

OBJECTIVES: The recommended evaluation of adult patients presenting with iron deficiency anemia (IDA) includes the performance of colonoscopy and esophagogastroduodenoscopy. IDA is a common feature in patients with celiac disease and, in several, may be the only presenting sign. The performance of small bowel biopsy (SBB) for the evaluation of celiac disease as the cause of IDA is not routinely recommended. The aim of the present study was to determine the yield of SBB performed during routine endoscopy of adults with IDA. METHODS: We prospectively studied 93 patients with IDA. Three control groups were included: 23 patients with steatorrhea, 37 patients with idiopathic diarrhea, and 9 patients in whom SBB was performed for miscellaneous indications. RESULTS: Eleven patients with IDA and two patients with steatorrhea had SBB findings compatible with celiac disease. None of the patients from the other two groups had similar findings. Two patients with IDA, who were later diagnosed to suffer from celiac disease, presented: one with occult blood in the stool and the other with rectal bleeding. Subgroup analysis of patients with IDA revealed that patients with celiac disease were younger, had significantly more episodes of diarrhea, lower mean hemoglobin level, and longer duration of anemia than those without celiac disease. Other mucosal abnormalities were found in a substantial number of patients with celiac disease: esophagitis, gastritis, duodenitis, hemorrhoids, and colitis. CONCLUSIONS: A substantial number of adult Israeli patients who present with IDA are found, on SBB, to have mucosal abnormalities compatible with the diagnosis of celiac disease. The presence of esophagitis, gastritis, or duodenitis on esophagogastroduodenoscopy, or other abnormalities on colonoscopy, do not exclude the coexistence of celiac disease. Celiac disease should be included and routinely looked for in the differential diagnosis of adult patients with IDA.     

Surgical clips: a cause of late recurrent gallstones

BACKGROUND: Oral iron supplements, which are usually in the form of ferrous (Fe2+) salts, are toxic to the gastrointestinal mucosa, and so intolerance is common, resulting in poor compliance and failure of treatment. The sugar derivative maltol strongly chelates iron, rendering it available for absorption and stabilized in the less toxic ferric (Fe3+) form. AIM: To test whether ferric trimaltol could correct iron deficiency anaemia in patients intolerant of ferrous sulphate. METHODS: Twenty-three patients were recruited from gastroenterology clinics, of whom 1 5 had inflammatory bowel disease, a group often difficult to treat with oral iron. Patients with iron deficiency anaemia and documented intolerance to ferrous sulphate were given 3 months of treatment with ferric trimaltol. RESULTS: Nineteen of 23 patients completed the treatment and anaemia was fully corrected in 14 of these, mean haemoglobin increased from 106 +/- 15 to 126 +/- 16 g/L, and there was a particularly low incidence of side-effects. Of 11 patients with inflammatory bowel disease who completed the study, nine fully corrected their anaemia. CONCLUSION: The results demonstrate that in patients intolerant of ferrous compounds, ferric trimaltol corrects iron deficiency and has a low incidence of side-effects.