Haemoglobin and anaemia in a gender perspective: the Tromsø Study

Abstract: Objectives: To examine the gender‐specific distribution of haemoglobin (Hb) and the World Health Organization (WHO) criteria for anaemia compared with the 2.5 percentile for Hb. Methods: A population‐based study from Tromsø, Northern Norway. All inhabitants above 24 yr were invited. In total, 26 530 (75%) had their Hb analysed. Results: The 2.5–97.5 percentile of Hb was 129–166 and 114–152 g/L for all men and women, respectively. In men, mean Hb decreased from 148 to 137 g/L between 55–64 and 85+ yr. In women, mean Hb increased from 132 to 137 g/L between 35–44 and 65–74 yr and then decreased to 131 g/L among the oldest. Using the WHO criteria for anaemia (Hb: <130 and <120 g/L, men and women respectively), the prevalence of anaemia in men increased with age from 0.6% aged 25–34 to 29.6% aged 85+. For women, the prevalence of anaemia varied from 9.1%, 2.2% and 16.5% in the age groups of 35–44, 55–64 and 85+ yr, respectively. The WHO criteria gave a two to three times higher prevalence of anaemia compared with the 2.5 percentile of Hb in women, but the difference was small in men. Poor self‐rated health was not associated with low values of Hb in women. In men, there was an association in some age groups. Conclusion: The WHO criteria for anaemia and the 2.5 percentile for Hb corresponded well for men, but not for women. The WHO criteria of anaemia may result in medicalization of healthy women.     

Haemoglobin concentrations appear to be lower in indigenous Greenlanders than in Danes: assessment of haemoglobin in 234 Greenlanders and in 2804 Danes

OBJECTIVE: To compare haemoglobin concentrations in Greenlanders and Danes. METHODS: Haemoglobin was measured in a population survey in 1993-1994 comprising 234 indigenous Greenlandic individuals (115 men) aged 19-82 yr. and in Copenhagen County 1983-1984 comprising 2804 Caucasian Danes (1444 men) aged 30-60 yr. The Greenlandic participants were residents in the capital Nuuk (n=70), the town Ilulissat (n=74), and four settlements in the Uummannaq district (n=90). The significance of differences was assessed by Student's t-test, and the xi2-test. Correlations were assessed by Spearman's correlation coefficient (rs). RESULTS: Greenlanders: Haemoglobin levels were not correlated with age or consumption of traditional foods, and were not significantly different in the three residential areas. Mean haemoglobin was higher in men, 146+/-9.6 (SD) g/L, than in women, 132+/-9.6 g/L (p<0.0001). Mean haemoglobin in iron-replete men with serum ferritin >32 microg/L (n=104) was 146+/-9.3 g/L, and in iron-replete women (n=68) 133+/-10.4 g/L (p<0.0001). The 5th percentile for haemoglobin in iron-replete men was 133 g/L (8.3 mmol/L) and in women 118 g/L (7.3 mmol/L). The prevalence of iron deficiency anaemia (i.e. ferritin <13 microg/L and Hb <5th percentile for iron-replete men and women) was 0% in men, 2.78% in women < or =50 yr of age and 0% in women >50 yr of age. Danes: Mean haemoglobin in men was 154+/-10.0 g/L and in women 138+/-10.4 g/L (p<0.0001). Haemoglobin in iron-replete men (n=1379) (i.e. serum ferritin >32 microg/L) was 154+/-10.7 g/L, and in iron-replete women (n=1003) 140+/-9.6 g/L (p<0.0001). Mean haemoglobin was lower in premenopausal than in postmenopausal women (p<0.0001). The 5th percentile for haemoglobin in iron-replete men was 137 g/L (8.5 mmol/L) and in women 124 g/L (7.7 mmol/L). The prevalence of iron deficiency anaemia (i.e. ferritin <13 microg/L and Hb <5th percentile for iron replete men and women) was 0% in men, 1.92% in women < or =50 yr of age and 0% in women >50 yr of age. CONCLUSION: Haemoglobin concentrations in Greenlanders were significantly lower than in Danes both in men (p<0.0001) and in women (p<0.0001). Delta(mean haemoglobin) in men was 8.0 g/L (0.5 mmol/L) and in women 6.2 g/L (0.4 mmol/L). Variations in haemoglobin levels may be due to genetic differences.     

Causes of microcytic anaemia and evaluation of conventional laboratory parameters in the differentiation of erythrocytic microcytosis in blood donors candidates*

ABSTRACT

Context and Objective: Microcytic anaemia results from defective synthesis of haemoglobin in the erythroid precursors, causing a reduction in its mean corpuscular volume (MCV). The most common causes of microcytosis, without the increase in HbA₂ levels, are iron deficiency anaemia (IDA) and α-thalassemia. The aim of this study was to identify the causes of microcytic anaemia and evaluate the haematological parameters from blood donors deemed ineligible (due to the low haematocrit level) that would differentiate the IDA and α-thal, whether isolated or in association.

Methods: Genomic DNA was submitted to the polymerase chain reaction multiplex for the diagnosis of the most common allele deletions of α-thal and erythrogram and in order to verify haematological parameters. Iron deficiency (ID) was determined through the measurement of serum ferritin.

Results: Of the 204 samples, 82 (40.2%) were identified with ID, 24 (17.8%) with α-thal and 10 (4.9%) with ID associated with α-thal. In the α-thal with ID group haemoglobin (Hb), MCV, mean corpuscular Hb concentration (MCHC) and mean corpuscular Hb (MCH) values were significantly lower compared to the isolated α-thal. In the group with ID Hb, MCV, MCHC and MCH values were significantly lower compared to those with isolated α-thal. The α-thal with ID group, showed Hb, MCV, MCHC and MCH significantly reduced when compared to those with IDA.

Conclusions: This study showed that the values of haematological parameters, especially haematocrit, Hb, MCV, MCH, MCHC and red blood cell distribution width (RDW), are lower in patients with IDA, especially when associated with α-thal and therefore it may be useful to discriminate between the different types of microcytic anaemia.     

Weekly iron supplements given by teachers sustain the haemoglobin concentration of schoolchildren in the Philippines

OBJECTIVES: To examine the effectiveness of weekly iron supplements given for 10 weeks by teachers to children in rural schools in the Philippines. METHODS: Forty-nine rural primary schools took part in the study and were randomly assigned to two groups: children in 25 schools received a weekly tablet providing 108 mg iron while children in 24 schools acted as controls. All children were dewormed before the start of the iron supplementation. The haemoglobin concentration of a systematic sample of one in three children in two classes in each school was estimated before and 5-17 weeks after the end of the iron supplementation. RESULTS: A total of 1510 children aged 7-12 years were studied at both surveys. The mean haemoglobin concentration of children in the intervention group did not change significantly; in the untreated group it fell by 3.8 g/l and the prevalence of anaemia rose from 14.3% to 25.6%. The difference between study groups was significantly larger amongst the younger children (7-8 years), and was observed in both anaemic and non-anaemic children. CONCLUSION: Even where anaemia is only a mild public health problem, weekly iron supplements given by teachers may prevent a fall in the haemoglobin concentration, and can benefit both anaemic and non-anaemic children.     

Transferrin receptor on peripheral blood lymphocytes in iron deficiency anaemia

The effect of iron deficiency anaemia (IDA) on CD71 expression by peripheral blood lymphocytes was studied in 43 children with iron deficiency anaemia. 18 healthy age-matched children were selected as the control group. 11 children with beta-thalassaemia trait were also studied. Lymphocytes bearing CD71 were enumerated by flow cytometric analysis of peripheral blood. At diagnosis, CD71+ peripheral lymphocytes (mean+/-SE) was 5.90+/-0-76% in patients with IDA and 12.60+/-0.98% in healthy controls (P=0.000). In beta-thalassaemia trait patients the peripheral blood CD71+ lymphocytes were 7.80+/-1.20%. In IDA patients there was a statistically significant correlation between the levels of CD71+ peripheral lymphocytes and haemoglobin value (P = 0.000). In 19 patients studied at days 0 and 30 of oral iron therapy, the number of peripheral blood CD71+ lymphocytes was shown to be increased from 5.90+/-0.76% to 12.11+/-1.21%. In severe IDA presence of a limited number of CD71+ peripheral blood lymphocytes indicated that severe IDA should be borne in mind when considering conditions responsible for the suppression of lymphocyte proliferation.     

Micronutrient and iron supplementation and effective antimalarial treatment synergistically improve childhood anaemia

The control of childhood anaemia in malaria holoendemic areas is a major public health challenge for which an optimal strategy remains to be determined. Malaria prevention may compromise the development of partial immunity. Regular micronutrient supplementation has been suggested as an alternative but its effectiveness remains unsettled. We therefore conducted a randomised placebo-controlled intervention trial with 207 Tanzanian children aged 5 months to 3 years on the efficacy of supervised supplementation of low-dose micronutrients including iron (Poly Vi-Sol with iron) three times per week, with an average attendance of >/= 90%. The mean haemoglobin (Hb) level increased by 8 g/l more in children on supplement (95% CI 3-12) during the 5-month study. All age groups benefited from the intervention including severely anaemic subjects. The mean erythrocyte cell volume (MCV) increased but Hb in children >/= 24 months improved independently of MCV and no relation was found with hookworm infection. The data therefore suggest that micronutrients other than iron also contributed to Hb improvement. In the supplement group of children who had received sulfadoxine-pyrimethamine (SP) treatment, the mean Hb level increased synergistically by 22 g/l (95% CI 13-30) compared to 7 g/l (95% CI 3-10) in those without such treatment. Supplementation did not affect malaria incidence. In conclusion, micronutrient supplementation improves childhood anaemia in malaria holoendemic areas and this effect is synergistically enhanced by temporary clearance of parasitaemia.     

Soluble transferrin receptor in Aboriginal children with a high prevalence of iron deficiency and infection

OBJECTIVES: Aboriginal children in tropical Australia have a high prevalence of both iron deficiency and acute infections, making it difficult to differentiate their relative contributions to anaemia. The aims of this study were to compare soluble transferrin receptor with ferritin in iron deficiency anaemia (IDA), and to examine how best to distinguish the effect of iron deficiency from infection on anaemia. METHODS: We conducted a prospective study of 228 admissions to Royal Darwin Hospital in children from 6 to 60 months of age. Transferrin receptor concentrations were measured by a particle-enhanced immunoturbidimetric assay and ferritin by a microparticle enzyme immunoassay. RESULTS: On multiple regression, the best explanatory variables for haemoglobin differences (r2=33.7%, P<0.001) were mean corpuscular volume (MCV), red cell distribution width (RDW) and C-reactive protein (CRP); whereas transferrin receptor and ferritin were not significant (P>0.4). Using > or =2 abnormal indices (MCV, RDW, blood film)+haemoglobin <110 g/l as the reference standard for IDA, transferrin receptor produced a higher area under the curve on receiver operating characteristic curve analysis than ferritin (0.79 vs. 0.64, P<0.001) or the transferrin receptor-ferritin index (0.77). On logistic regression, the effect of acute infection (CRP) on haemoglobin was significant (P<0.001) at cut-offs of 105 and 110 g/l, but not at 100 g/l when only iron deficiency indicators (MCV, RDW, blood film) were significant. CONCLUSIONS: Transferrin receptor does not significantly improve the diagnosis of anaemia (iron deficiency vs. infection) over full blood count and CRP, but in settings with a high burden of infectious diseases and iron deficiency, it is a more reliable adjunctive measure of iron status than ferritin.     

Relationship of measles vaccination with anaemia and malaria in western Kenya

OBJECTIVE: Mild viral illness, including that following immunization with live attenuated measles virus (LAMV), has been associated with transient decreases in haemoglobin (Hb) and cellular immune response that may persist for several weeks. In areas of intense malaria transmission, such as western Kenya, infants experience a progressive drop in Hb until age 9-10 months and one-third may have Hb < 8 g/dl. These children may be at risk of developing severe anaemia with further haematological insult. The objective of this paper was to determine if immunization with LAMV was associated with increased risk of transient anaemia and malaria infection. METHODS: Data from previous cross-sectional surveys (n = 5970) and one cohort study (n = 546) conducted among pre-school children were analyzed retrospectively. RESULTS: Measles vaccination coverage between 12 and 23 months of age ranged from 44.8% to 62.7%. Hb concentrations in children aged 6-23 months with documented measles immunization within the previous 14 or 30 days (n = 103) were similar to those with no history of measles immunization in the previous 90 days (n = 996); mean differences [95% confidence interval (CI)] by 30 days were: in cross-sectional surveys, -0.49 g/dl (-1.12, 0.14); in the cohort study, -0.032 g/dl (-0.52, 0.46). Similarly, the risk of malaria parasitemia or severe to moderate anaemia did not differ. CONCLUSION: These data do not suggest that the transient decrease in Hb and cellular immune response after immunization with LAMV results in clinically significant changes in the risk of subsequent severe to moderate anaemia or malaria in young children living in malaria-endemic regions.     

Recognition of pallor associated with severe anaemia by primary caregivers in western Kenya

OBJECTIVES: To explore which pallor signs and symptoms of severe anaemia could be recognized by primary caregivers following minimal instructions. METHODS: Data from three community-based cross-sectional surveys were used. Test characteristics to predict haemoglobin (Hb) concentrations < 5 and < 7 g/dl were compared for different combinations of pallor signs (eyelid, tongue, palmar and nailbed) and symptoms. RESULTS: Pallor signs and haemoglobin levels were available for 3782 children under 5 years of age from 2609 households. Comparisons of the sensitivity and specificity at a range of haemoglobin cut-offs showed that Hb < 5 g/dl was associated with the greatest combined sensitivity and specificity for pallor at any anatomical site (sensitivity = 75.6%, specificity = 63.0%, Youden index = 38.6). Higher or lower haemoglobin cut-offs resulted in more children being misclassified. Similar results were obtained for all individual pallor sites. Combining a history of soil eating with pallor at any site improved the sensitivity (87.8%) to detect Hb < 5 g/dl with a smaller reduction in specificity (53.3%; Youden index 41.1). Other combinations including respiratory signs or poor feeding resulted in lower accuracy. CONCLUSION: Primary caregivers can recognize severe anaemia (Hb < 5 g/dl) in their children, but only with moderate accuracy. Soil eating should be considered as an additional indicator of severe anaemia. The effect of training caretakers to improve recognition of severe anaemia and care-seeking behaviour at the household level should be assessed in prospective community-based studies.     

Impact of malaria control on childhood anaemia in Africa -- a quantitative review

OBJECTIVE: To review the impact of malaria control on haemoglobin (Hb) distributions and anaemia prevalences in children under 5 in malaria-endemic Africa. METHODS: Literature review of community-based studies of insecticide-treated bednets, antimalarial chemoprophylaxis and insecticide residual spraying that reported the impact on childhood anaemia. Anaemia outcomes were standardized by conversion of packed cell volumes into Hb values assuming a fixed threefold difference, and by estimation of anaemia prevalences from mean Hb values by applying normal distributions. Determinants of impact were assessed in multivariate analysis. RESULTS: Across 29 studies, malaria control increased Hb among children by, on average, 0.76 g/dl [95% confidence interval (CI): 0.61-0.91], from a mean baseline level of 10.5 g/dl, after a mean of 1-2 years of intervention. This response corresponded to a relative risk for Hb < 11 g/dl of 0.73 (95% CI: 0.64-0.81) and for Hb < 8 g/dl of 0.40 (95% CI: 0.25-0.55). The anaemia response was positively correlated with the impact on parasitaemia (P = 0.005, P = 0.008 and P = 0.01 for the three outcome measures), but no relationship with the type or duration of malaria intervention was apparent. Impact on the prevalence of Hb < 11 g/dl was larger in sites with a higher baseline parasite prevalence. Although no age pattern in impact was apparent across the studies, some individual trials found larger impacts on anaemia in children aged 6-35 months than in older children. CONCLUSION: In malaria-endemic Africa, malaria control reduces childhood anaemia. Childhood anaemia may be a useful indicator of the burden of malaria and of the progress in malaria control.     

Evaluation of overnight storage conditions for autologous peripheral blood stem cell products: comparison of three different conditions

Background and Objectives Preoperative diagnosis and treatment of anaemia are important to minimize adverse postoperative outcomes. This audit reviewed red cell transfusion practice, degree of anaemia, iron deficiency anaemia (IDA) and chronic disease or anaemia of inflammation (AI) in cardiothoracic and orthopaedic surgical patients who had available iron studies. Materials and Methods A total of 178 consecutive cardiothoracic and orthopaedic surgical patients with available iron studies were retrospectively reviewed. Results Of patients, 36·5% had preoperative iron studies. However, 63·2% males and 45·3% females with postoperative iron studies presented with anaemia; 38·5% patients with preoperative iron studies had AI; 21·5% IDA; 23·1% normal. For patients with iron studies requested within the first two postoperative intervals (≤5 days and 6 ≤ 10 days) 73·8% and 63·6%, respectively, had AI; few had classical IDA or were normal, and 51·5% patients transfused postsurgery had a discharge Hb ≥110 g/l. Restricting the discharge Hb to 90 or 100 g/l may have eliminated postsurgical transfusion in 14·8–42·6% patients. Conclusion Iron studies were more commonly requested postoperatively despite many being anaemic at admission. A higher proportion of patients with postoperative iron studies had AI, and few had classical IDA or normal iron parameters, suggesting a transient inflammatory effect of surgery. This may mask underlying IDA or normal iron parameters and affect treatment. Preadmission assessment, including iron status, should be emphasized allowing diagnosis and correction of presurgical anaemia with treatment modalities other than red cell transfusion. In the postsurgical setting, consideration of a restrictive transfusion regimen sufficient to alleviate a patient’s clinical symptoms would ensure that this valuable resource is appropriately used.     

Severe anaemia in children living in a malaria endemic area of Kenya

Severe anaemia is an important cause of morbidity and mortality in African children, but the causes, particularly falciparum malaria, are difficult to determine. We assessed the contribution of falciparum malaria to anaemia in Kenyan children by clinical examination and measurement of parasitaemia and haemoglobin (Hb) concentration in 559 children in the community and in 2412 children admitted to Kilifi district hospital during a 2‐year period. We also attempted to characterize severe malarial anaemia by examining the causes and pathophysiology of anaemia in 101 children admitted with Hb concentration 50 g/l during a 1‐year period. Plasmodium falciparum infection was associated with reduced Hb concentration in children in the community and in those admitted to hospital irrespective of diagnosis. Falciparum malaria was the primary cause in 46 cases (46%) of severe anaemia admitted to hospital. There was no difference in the frequency of haemolysis or dyserythropoiesis in the children with malarial anaemia and those with anaemia from other causes, such as iron deficiency or sickle cell disease. The mortality rate in the children with severe malarial anaemia was 8.6% compared with 3.6% in children with severe anaemia due to other causes. Falciparum malaria does not present with a characteristic clinical or haematological picture, but is a major cause of the morbidity and mortality in children with severe anaemia who live on the Kenyan coast, a malaria endemic area.     

Reduced erythropoietin response to anaemia in elderly patients with normocytic anaemia.

We studied the effect of age on the relationship between haemoglobin and serum erythropoietin (EPO) levels in anaemic patients. 568 patients over 70 years of age were compared with 137 patients under 70 and a reference group of 144 patients of all ages with proven iron deficiency. EPO was measured using a radioimmunoassay. We found that elderly patients with a normocytic anaemia (N = 375) had a statistically lower EPO response than younger patients with normocytic anaemia (N = 61) (p < 0.05) or patients of all ages with iron-deficiency anaemia (p < 0.05). There was no difference between the sexes. Elderly patients with microcytic or macrocytic anaemia had a normal EPO response as compared to the "gold standard" of iron deficiency. These findings suggest that a proportion of elderly patients with normocytic anaemia has an impaired EPO response.     

A fast-track anaemia clinic in the Emergency Department: feasibility and efficacy of intravenous iron administration for treating sub-acute iron deficiency anaemia

Background

Clinically significant anaemia, requiring red blood cell transfusions, is frequently observed in Emergency Departments (ED). To optimise blood product use, we developed a clinical protocol for the management of iron-deficiency anaemia in a fast-track anaemia clinic within the ED.

Materials and methods

From November 2010 to January 2014, patients presenting with sub-acute, moderate-to-severe anaemia (haemoglobin [Hb] <11 g/dL) and confirmed or suspected iron deficiency were referred to the fast-track anaemia clinic. Those with absolute or functional iron deficiency were given intravenous (IV) ferric carboxymaltose 500–1,000 mg/week and were reassessed 4 weeks after receiving the total iron dose. The primary study outcome was the haematological response (Hb≥12 g/dL and/or Hb increment ≥2 g/dL). Changes in blood and iron parameters, transfusion rates and IV iron-related adverse drug effects were secondary outcomes.

Results

Two hundred and two anaemic patients with iron deficiency (150 women/52 men; mean age, 64 years) were managed in the fast-track anaemia clinic, and received a median IV iron dose of 1,500 mg (1,000–2,000 mg). Gastro-intestinal (44%) or gynaecological (26%) bleeding was the most frequent cause of the anaemia. At follow-up (183 patients), the mean Hb increment was 3.9±2.2 g/dL; 84% of patients were classified as responders and blood and iron parameters normalised in 90%. During follow-up, 35 (17%) patients needed transfusions (2 [range: 1–3] units per patient) because they had low Hb levels, symptoms of anaemia and/or were at risk. Eight mild and one moderate, self-limited adverse drug effects were witnessed.

Discussion

Our data support the feasibility of a clinical protocol for management of sub-acute anaemia with IV iron in the ED. IV iron was efficacious, safe and well tolerated. Early management of anaemia will improve the use of blood products in the ED.     

Possible ameliorative effect of taurine in the treatment of iron-deficiency anaemia in female university students of Gaza,Palestine

The aim of the study was to evaluate the haematological effects of adding the antioxidant taurine to iron sulfate in the treatment of iron-deficiency anaemia (IDA). A sample of 730 students from Al-Azhar University, Gaza, in Palestine underwent screening with complete blood counts and serum samples. In subjects with microcytosis/hypochromasia, Alpha2 delta2 (HbA2) and serum concentrations of iron, total iron binding capacity (TIBC), ferritin and taurine were determined. Samples from 17 normocytic, normochromic, and non-anaemic subjects were used as baseline controls. At base-line, 81 of the 730 subjects (11.1%) had microcytosis/hypochromasia, 26 (3.6%) were diagnosed as beta-thalassemia carriers, none of which was iron deficient. Four subjects had microcytosis of unknown cause. Fifty-one subjects (all females) had iron-deficiency anaemia and were included in the therapeutic study, which lasted for 20 wk. They were matched for Hb into pairs and were treated with oral iron (325 mg of slow-release iron sulfate). In addition, they were, in a double-blind procedure, randomised to additional oral taurine (1000 mg d(-1) at a cost comparable to that of adding ascorbic acid) or placebo. Mean S-taurine was significantly lower in the IDA subjects than in the controls. After 20 wk of iron supplementation, both the taurine and placebo group significantly improved their Hb concentrations and normalised the markers of iron deficiency. Apart from the expected, albeit in this study mild side-effects of oral iron, no significant side-effects were noted. In the taurine group, there was a statistically significant additive positive change from the baseline values on Hb (2.67 +/- 1.24 g dL(-1)), red blood cell (RBC) count [(0.57 +/- 0.25) x 1012 L(-1)] and serum ferritin (30.33 +/- 17.99 microg L(-1)) as compared to placebo group values, which were 1.80 +/- 1.10 g dL-1, (0.39 +/- 0.36) x 1012 L(-1), and 20.11 +/- 7.34 microg L(-1), respectively. Oral taurine appears to increase the effectiveness of oral iron in the treatment of IDA, and has no significant side-effects. This merits further cost-benefit and clinical analyses.     

Safety and efficacy of intravenous iron isomaltoside for correction of anaemia in patients with inflammatory bowel disease in everyday clinical practice

Aims: Iron deficiency anaemia (IDA) is common in patients with inflammatory bowel disease (IBD), who are often treated with intravenous iron. This observational study aimed to investigate the effectiveness and safety of iron isomaltoside in routine practical care of IDA in IBD patients.

Methods: The study included 197 IBD patients designated for treatment with iron isomaltoside. Treatment was administered according to routine practice. Data were recorded at baseline and after approximately 4, 8, and 16 weeks. Efficacy data included haemoglobin (Hb) levels and haematinics, while safety data included adverse drug reactions and safety laboratory variables.

Results: Patients received a mean (range) cumulative dose of 1304 (100–3500) mg iron isomaltoside. Hb increased from 10.7(±1.6) g/dL at baseline to 13.1(±1.5) g/dL at the final visit. In addition, serum iron, ferritin and transferrin saturation increased and soluble transferrin receptor decreased. Calprotectin decreased, as did IBD symptom scores, Harvey–Bradshaw Index (Crohn’s disease) and partial Mayo score (Ulcerative colitis). About 8% of patients reported transient adverse reactions, most commonly skin reactions, nausea and vomiting, and 2% SAEs, most frequently tachycardia.

Conclusion: Iron isomaltoside was demonstrated to be effective and had a good safety profile in IBD patients in everyday clinical practice in Germany.     

Comparison of screening methods for anaemia in pregnant women in Awassa,Ethiopia

Screening for anaemia in pregnancy is essential for implementing and monitoring effective antenatal programmes. We compared the diagnostic accuracy of invasive and non-invasive screening methods in a cross-sectional survey of 403 pregnant women attending an urban health centre in Awassa, southern Ethiopia. Overall anaemia prevalence [haemoglobin (Hb): <11 g/dl] was 15.1% (95% CI: 12.1-19.9), mild anaemia (Hb: 10-10.9 g/dl) 10.4%, moderate anaemia (Hb: 7-9.9 g/dl) 4.2% and severe anaemia (Hb < 7 g/dl) 0.3%. Sensitivity, specificity and predictive values of conjunctival pallor and the WHO Hb colour scale were calculated for Hb cut-off points <11, <10 and <9 g/dl. All methods in combination with the symptoms and complaints reported by the mothers were entered into a predictive scoring system. None of the methods tested or models predicted anaemia with suitable accuracy in this population. The diagnosis of anaemia based on clinical signs and symptoms remains unreliable despite attempts to develop predictive models.     

A Prospective Randomised Controlled Trial of a Single Intravenous Infusion of Ferric Carboxymaltose vs Single Intravenous Iron Polymaltose or Daily Oral Ferrous Sulphate in the Treatment of Iron Deficiency Anaemia in Pregnancy

Iron deficiency anaemia (IDA) is the most common nutritional deficiency affecting pregnant women worldwide. This study aims to compare the efficacy and safety of a newly available intravenous (IV) iron preparation, ferric carboxymaltose (FCM), against IV iron polymaltose (IPM), and standard oral iron (ferrous sulphate) for the treatment of IDA in pregnancy. This is an open-labelled prospective randomised controlled trial (RCT) with intention-to-treat analysis conducted at a primary health care facility with a single tertiary referral centre in Launceston. Tasmania, Australia. A 3-arm randomised controlled trial was conducted comparing a single IV infusion of 1000 mg of FCM (n = 83 patients) over 15 minutes against a single IV infusion of 1000 mg of IPM (n = 82) over 2 hours against 325 mg daily oral ferrous sulphate (n = 81) until delivery, for the treatment of IDA in pregnancy. A total of 246 consecutive pregnant women were recruited between September 2013 and July 2014. The median age was 28 years, with a median and mean gestation of 27 weeks. The median serum ferritin was 9 µg/L, with a mean of 13 µg/L. The mean haemoglobin (Hb) was 114 g/L. The primary outcome was the change in ferritin and Hb levels at 4 weeks after intervention. Secondary outcomes included ferritin and Hb improvements at predelivery, safety, tolerability, quality of life (QoL), cost utility, and fetal outcomes. The mean Hb level differences between the baseline intervention time point and 4 weeks thereafter were significantly higher in the FCM versus the oral group by 4.35 g/L (95% CI: 1.64-7.05; P = 0.0006) and in the IPM vs the oral group by 4.08 g/L (95% CI: 1.57-6.60; P = 0.0005), but not different between the FCM and IPM groups (0.26 g/L; 95% CI: −2.59 to 3.11; P = 0.9740). The mean ferritin level differences were significantly higher at 4 weeks in the FCM vs oral iron group by 166 µg/L (95% CI: 138-194; P < 0.0001) and in the IPM vs oral iron group by 145 µg/L (95% CI: 109-1180, P < 0.0001), but not between the 2 IV groups (21.5 µg/L; 95% CI: −23.9 to 66.9; P = 0.4989). Administration of IV FCM during pregnancy was safe and better tolerated than IV IPM or oral iron. Compliance to oral iron was the lowest amongst treatment groups with one-third of the patients missing doses of daily iron tablets. Significant improvement in overall QoL scores was observed in both IV iron supplement groups by achieving normal ferritin following effective and prompt repletion of iron stores, compared to the oral iron group (P = 0.04, 95% CI: 21.3, 1.8). The overall cost utility of IV FCM and IV IPM appear to be similar to oral iron. There were no differences in the fetal outcomes between the 3 trial arms.In conclusion, this study demonstrates that a single IV iron infusion is an effective and safe option for treatment of IDA during pregnancy. FCM was more convenient than other treatments. Rapid parenteral iron repletion can improve iron stores, Hb levels and QoL in pregnant women, with ongoing benefits until delivery. Integration of IV iron for IDA in pregnancy can potentially improve pregnancy outcomes for the mother. Update of guidelines to integrate the use of new IV iron preparations in pregnancy is warranted.     

Clinical and molecular analysis of haemoglobin H disease in Sardinia: haematological, obstetric and cardiac aspects in patients with different genotypes

In this study, 251 Sardinian patients (187 adults and 64 children) with haemoglobin (Hb) H disease were evaluated. Two-hundred and sixteen patients (86%) had the deletional type (- -/-alpha) and 36 (14%) patients had the non-deletional type (- -/alpha(ND)alpha). A clear genotype-phenotype correlation was found, with the non-deletional type more severe than the deletional type. Diagnosis of Hb H disease was incidental in about 60% of cases. Aplastic crises due to B19 parvovirus infection were found in five patients (2.1%), while 23 patients (9.6%) experienced one or more haemolytic crises. Nineteen patients with Hb H received sporadic red blood cell transfusions and three patients were repeatedly transfused. Forty-seven of 61 married women (77%) had 82 pregnancies. In children, mean serum ferritin was 87 +/-92 mug/l and in adults, was 192 +/- 180 mug/l in females and 363 +/- 303 mug/l in males. For the 98 male patients, a significant correlation was found between ferritin values and age (r2 = 0.33, P < 0.0001). In the Sardinian population, Hb H disease needs regular monitoring for early detection and treatment of possible complications, such as worsening of anaemia that may require red cell transfusion, cholelithiasis and iron overload.     

Delayed cord clamping and haemoglobin levels in infancy: a randomised controlled trial in term babies

OBJECTIVES: This study was carried out to assess whether delaying umbilical cord clamping is effective in improving the haematological status of term infants living in a malaria-endemic area, and whether this is associated with complications in infants and mothers. METHODS: We randomly assigned women delivering term babies in Mpongwe Mission Hospital, Zambia, to delayed cord clamping (DCC, n = 46) or immediate cord clamping (controls, n = 45) and followed their infants on a bi-monthly basis until the age of 6 months. We compared the haemoglobin (Hb) change from cord values and the proportion of anaemic infants. Secondary outcomes related to infant and maternal safety. RESULTS: Throughout the observation period infant Hb levels in both groups declined, but more rapidly in controls than in the DCC group [difference in Hb change from baseline at 4 months 1.1 g/dl, 95% confidence interval (CI) 0.2; 2.1]. By 6 months, this difference had disappeared (0.0 g/dl, 95% CI -0.9; 0.8). The odds ratio for iron deficiency anaemia in the DCC group at 4 months was 0.3 (95% CI 0.1; 1.0), but no differences were found between the groups at 6 months. No adverse events were seen in infants and mothers. CONCLUSION: Our findings indicate that DCC could help improve the haematological status of term infants living in a malaria-endemic region at 4 months of age. However, the beneficial haematological effect disappeared by 6 months. This simple, free and safe delivery procedure might offer a strategy to reduce early infant anaemia risk, when other interventions are not yet feasible.