Ferritin Tests Research Articles

Prevalence of Iron Deficiency and Iron Deficiency Anemia during Pregnancy: A Single Centre Canadian Study

Background Iron deficiency (ID) is the most common and widespread nutritional deficiency in both developing and developed countries (Mei et al., 2011; World Health Organization, 2001). Women of childbearing potential are at highest risk of ID due to regular menstrual losses as well as the increased iron demands of pregnancy and lactation (Lynch, 2011; McMahon, 2010). During pregnancy, the risk for ID and iron deficiency anemia (IDA) increases due to the additional iron requirements to support expansion of blood volume/red cell mass and growth of the fetus and placenta (McMahon, 2010; Mei et al., 2011). Common symptoms of ID with or without anemia during pregnancy include fatigue, shortness of breath, difficulty concentrating, higher rates of preterm delivery, and red blood cell transfusions (World Health Organization, 2001). Poor prenatal iron status is also associated with diminished cognitive performance, language ability, and motor functions in the child (Tamura et al., 2002). Despite international recommendations and guidelines on the screening and management of ID in pregnancy, it remains a problem of epidemic proportions and is often left unrecognized and untreated. To increase recognition and appropriate management of ID and IDA in pregnancy, we developed and implemented a quality improvement project, the IRON Deficiency project in Pregnancy: Maternal Iron Optimization (IRON MOM). This project was implemented January 1st, 2017 at St. Michael's Hospital (SMH), an inner-city tertiary centre in Toronto, Canada. The IRON MOM included educational resources for clinicians and patients, standardized oral iron prescriptions, modified lab requisitions, and clinical pathways to guide the screening, diagnosis and management of ID for obstetricians. Objective The primary objective of this study was to assess the prevalence of ID and IDA in unselectively screened pregnant women after the implementation of the IRON MOM quality improvement project. Methods We performed a retrospective audit of administrative laboratory data collected from all obstetrical clinics between January 1 and December 31, 2017. ID was defined as a serum ferritin <50μg/L (Guyatt et al., 1992) . IDA was defined as a dual diagnosis of ID and anemia based on hemoglobin levels <110 g/L and ferritin levels <50μg/L. Descriptive statistics were used to calculate frequencies and proportions. SAS version 9.4 was used to perform the analyses. Results A total of 1830 pregnant women were screened for ID during their obstetrical visit. Of the 1830 pregnant women, 1307 had one ferritin test and 523 pregnant women had two or more tests. A total of 91.3% (1193/1307) of pregnant women were iron deficient (ferritin <50μg/L) where 31.5% (411/1307) had ferritin levels between 15-29μg/L, and 49.4% (645/1307) had severe ID (ferritin <15μg/L). For the women who had two or more ferritin tests, 78.6% (411/ 523) were iron deficient at the first visit which then increased to 96.2% (503/523) by their second visit. When ferritin and hemoglobin values were linked and measured on the same day, 25.9% (346/1336) of pregnant women had IDA over the course of their outpatient care. Conclusion After the implementation of the IRON MOM, we found an extremely high prevalence of ID in our pregnant patient population in the outpatient setting. This confirms that ID remains an underappreciated problem, even at a tertiary care centre. Our findings highlight a tremendous gap in awareness, which demands strategies to improve knowledge translation. Future directions include the simplification and digitization of IRON MOM to empower pregnant women to advocate for their care. Disclosures Sholzberg: Novartis: Honoraria; Amgen: Honoraria, Research Funding.

Diagnosing Absolute Iron-Deficiency Anemia in Patients on Hemodialysis in a Tertiary Care Centre: A Retrospective Chart Review

Introduction: The gold standard for the diagnosis of absolute iron-deficiency anemia (IDA) in hemodialysis patients is a bone marrow aspirate with iron staining. Many clinicians use peripheral iron indices instead because they are non-invasive. Previous studies suggested that a serum ferritin < 200 ng/mL was a reliable indicator of absolute iron deficiency in the hemodialysis population. However, the sensitivity of serum ferritin for the diagnosis of IDA in hemodialysis patients is poor. Methods: The primary objective of this study was to identify the optimal ferritin value to diagnose patients with absolute iron deficiency, as assessed on bone marrow aspiration, in the renal dialysis population. Secondary endpoints included the rate of clinically relevant findings on gastrointestinal investigation according to iron status. Research Ethics Board approval was obtained from Queen's University for this retrospective chart review. Hematopathology laboratory records were used to determine all individuals who had bone marrow examination at Kingston Health Sciences tertiary referral center between 2008 January 1 and 2018 August 21. This list was cross-referenced with the Nephrology dialysis database to identify the pre-specified study cohort; those who were receiving concurrent hemodialysis or peritoneal dialysis. Iron deficiency was defined as reduced or absent iron stores on bone marrow aspirate with Perl's Prussian blue stain. Anemia was defined as hemoglobin <130 g/L in males and <120 g/L in females. Additional parameters collected included ferritin (normal range 22 - 275 ng/mL male and 4 - 205 ng/mL female), transferrin saturation (TSAT, normal range 20-55%), vitamin B12, folate, albumin, CRP and thyroid function tests. Peripheral iron indices over six months were analyzed; statistical analysis was performed with t-tests and Mann-Whitney U tests. ROC curves were generated to determine the sensitivity and specificity of various threshold values for serum ferritin and TSAT. Results: Between 2008 January 1 and 2018 August 21, 4234 patients underwent bone marrow examination, of whom 28 had received renal dialysis replacement therapy at some point. Fifteen patients concurrently at the time of bone marrow testing receiving hemodialysis form the study population (Table 1). Among these fifteen patients, 6 (40%) were female, median age was 70.5 (range 39 - 80) years and all were anemic (Hb range 73 - 110 g/L). Four of these individuals were absolutely iron-deficient with reduced or absent iron stores by bone marrow evaluation. The mean ferritin and TSAT values for individuals with absolute iron deficiency by bone marrow aspiration was 273.5 ng/mL (n=4; median 224.5 ng/mL; range 158-539 ng/mL) and 22.0% (n=3; median 20%; range 20-26%), respectively. All four commenced erythropoietin stimulating agents; two received oral iron supplementation. Eight patients, including two of those determined to be absolutely iron deficient on bone marrow, had endoscopic investigation. Two were identified to have sources of gastrointestinal bleeding, both with ferritin values in the 100-200 range (106 and 189 ng/mL). With the limited sample size, the sensitivity and specificity of ferritin to identify absolute iron deficiency in this hemodialysis population was 50% and 85%, respectively, at a threshold of 198 ng/mL. Discussion: Ferritin and TSAT are not sensitive markers for absolute iron deficiency in hemodialysis patients. Bone marrow examination is performed in a minority. The small sample size in this study precludes definitive determination of an optimal ferritin cut-off to diagnose iron deficiency in the dialysis population. Uncertainty about actual iron status may result in alternative invasive testing, such as colonoscopy, to investigate the cause of their anemia. Newer tests such as reticulocyte hemoglobin content and percent hypochromic red blood cells are more accurate and may guide diagnosis and management of IDA in hemodialysis patients. However they are not always routinely available. Further studies are needed to compare the utility of these peripheral iron indices to the gold standard bone marrow examination in a larger population, to allow identification of patients with absolute or functional IDA, and minimize invasive and potentially unnecessary investigation. Disclosures Hay: AbbVie: Research Funding; Kite: Research Funding; Janssen: Research Funding; Seattle Genetics: Research Funding; Celgene: Research Funding; MorphoSys: Research Funding; Roche: Research Funding; Novartis: Research Funding; Gilead: Research Funding; Takeda: Research Funding.

Reference intervals established using indirect method for serum ferritin assayed on Abbott Architect i2000SR analyzer in Chinese adults.

BackgroundSerum ferritin (SF) test has been widely used in clinical practice. However, its reference intervals (RIs) vary depending on the analytical method and ethnic origin. This study was to establish the RIs using indirect method for SF in Chinese adults.MethodsSF was assayed on Abbott i2000SR analyzer. The SF test results of all health examinees (8913 males aged 18‐93 years and 5397 females aged 18‐90 years) between December 2010 and April 2019 were obtained from our laboratory information system. After Box‐Cox transformation of raw data and exclusion of outliers, parametric and non‐parametric approaches were used to calculate 95% RIs. The correlation between SF levels and ages, and the differences in SF levels between subgroups were also analyzed.ResultsSF levels in females were significantly different from those in males (Z = 88.96, Z* = 23.17; Z > Z*) and showed a weak positive correlation with age (r = .466, P < .0001). The RIs based on parametric approach in males were 66.12‐561.58 µg/L, whereas in all females were 3.59‐269.59 µg/L, females aged <50 years 3.26‐148.02 µg/L and those aged ≥50 years 17.28‐303.27 µg/L. The RIs based on non‐parametric approach in males were 65.00‐571.37 µg/L whereas in all females were 4.00‐254.00 µg/L, females aged <50 years 4.00‐152.00 µg/L and those aged ≥50 years 16.00‐304.05 µg/L.ConclusionsOur indirect RIs for SF were markedly different from the manufacturer's recommended RIs and might be more suitable for Chinese adults, which would be helpful in interpreting laboratory data and clinical decision‐making.

Status of Serum Ferritin, C-Reactive Protein and Liver Function Tests in Pulmonary Tuberculosis

Status of Serum Ferritin, C-Reactive Protein and Liver Function Tests in Pulmonary Tuberculosis

Status of Serum Ferritin, C-Reactive Protein and Liver Function Tests in Pulmonary Tuberculosis

Status of Serum Ferritin, C-Reactive Protein and Liver Function Tests in Pulmonary Tuberculosis

The Effect of Iron Replacement Therapy on Electrocardiographic Consequences in Pediatric Patients

Background Sudden cardiac death is an important problem, because the patients have no opportunity to receive medical service. Recently some electrocardiogram (ECG) parameters are used for predicting arrhythmias, including P wave duration for predicting atrial arrhythmias and corrected QT and T wave peak to end interval (Tp-e), for predicting ventricular arrhythmias. Iron deficiency is the most prevalent nutrient disorder worldwide in which iron loads in different tissues including myocardium are decreased. We aimed to investigate the relationship between iron deficiency and arrhythmogenic ECG parameters. Then we compared electrocardiographic parameters of iron deficient patients before and after iron replacement therapy. Materials and Methods In the first phase of study, ECG and blood samples were taken from 9-18 years old healthy adolescents for CBC and ferritin tests. They were divided into three groups according to serum ferritin: group 1 (ferritin below 15), group 2 (ferritin 15-30), and group 3 (ferritin above 30) ng/ml. In phase two, group 1 were given standard iron replacement therapy. We compared ECG parameters in three groups and then in group 1 before and after treatment. Results The number of individuals in three groups was 120 (group 1= 25, group 2= 26 and group 3= 69). The results showed that all parameters were significantly higher in group one and the lowest in group three. Also, there was a significant decrease in these parameters after treatment in group one (P<0.05). Conclusion Based on the results, Iron deficiency through decreased myocardial iron load can prolong ECG parameters and elevate risk of arrhythmia. Also, iron replacement therapy can reduce this risk.

Expanded feasibility of ferritin testing: stability of ferritin stored as whole blood and validation of plastic tubes.

Ferritin testing is a recommended strategy to mitigate iron depletion in blood donors. A barrier for some testing platforms is a requirement to complete sample management and testing within a temporal window incompatible with the logistics of many blood collectors. The ability to delay separation of plasma/serum from red cells and subsequent testing would enhance the feasibility of ferritin testing on a broader scale. Thirty blood donors provided a research donation of 12, 4-mL sample tubes of whole blood. Six pairs of serum and K2 -EDTA-plasma tubes were centrifuged and samples tested in triplicate on day of collection and on each of the next 5 days following storage at 4°C. Comparison of ferritin values for serum versus K2 -EDTA-plasma at baseline was performed to validate plastic EDTA-containing tubes. Variation of ferritin values during storage was assessed for direction and strength of any detectable changes. Ferritin values were comparable between EDTA-plasma and serum, with baseline values from EDTA-plasma samples 7% lower on average than serum (p < 0.0001 by paired t-test). Variability over five storage days was within approved parameters in the manufacturer's instructions. Within-run precision averaged 2% to 3% for each test day and within-subject precision across all samples averaged less than 5% for both serum and EDTA-plasma. Repeated measures showed no difference in changes during storage by tube type or day of testing. These results support flexible testing procedures, expanding the opportunity for blood centers to adopt this measure for assessing donor iron status.

35. A referred case of probable PMR with a different outcome

IntroductionThis is the case of a 67-year-old woman who presented to the rheumatology clinic with suspected diagnosis of polymyalgia rheumatica on prednisolone with complaints of flu-like illness, muscle aches and occasionally low-grade fever. Initial investigation showed anaemia with a significantly raised CRP and ESR. Further investigation revealed a different outcome.Case descriptionA 67-year-old woman presented to the rheumatology clinic with the suspected diagnosis of polymyalgia rheumatica with prednisolone commenced in primary care. Three months before, she presented in primary care with a flu-like illness, muscle aches and occasionally low-grade fever. On investigation, she was found to have anaemia (Hb 92 gm/dl with MCV of 109 femtoliters per cell) with a significantly raised ESR of 123 mm/hr and CRP of 258 mg/L. Initially, there was a history of mild weight loss which she attributed to her diet and subsequently, she regained weight.Her symptoms were not typical of PMR and upon further questioning, she complained of shortness of breath on inclines. She denied any symptoms of dizziness or any symptoms suggestive of embolic manifestation. Her previous medical history includes hypertension and hyperlipidemia for which she was on bendroflumethiazide and statins which were stopped in primary care three months back. Her blood pressure in the clinic was 156/77mmHg with a pulse of 82 beats per minute. There was no clubbing or any signs suggestive of polymyalgia rheumatica or any other connective tissue disease. On auscultation of heart, the first heart sound was loud and the chest was clear. Abdominal and neurological examination was unremarkable. Rest of investigations including urea and electrolytes, liver function test, ANA, anti ENA, Complement C3 &C4, immunoglobulins, creatine kinase, ferritin and thyroid function tests were unremarkable. An echocardiogram was requested as workup of unexplained raised inflammatory markers and non-resolving symptoms which showed a large echogenic mass in the left atrium attached to atrial septum and prolapsing through the mitral valve into the left ventricle, suggestive of left atrial myxoma. She was referred to cardiothoracic surgeons for resection. Her aches and pains subsided and she is doing very well after surgery. DiscussionMyxomas account for 40-50% of primary cardiac tumours. 75-85% occur in the left atrial cavity and up to 25% in the right atrium. Symptoms range from nonspecific and constitutional to sudden cardiac death. In 20% of cases, atrial myxoma may be asymptomatic and reported as an incidental finding. Other reported symptoms are exertional dyspnoea (75%) which may get worse leading to pulmonary oedema. Other symptoms may be due to obstruction of mitral valve leading to dizziness (20%), Symptoms of right heart failure, embolization to the central nervous system and retinal artery involvement may lead to blindness, coronary artery disease, and PE. Constitutional symptoms include fever, weight loss, arthralgias, and Raynaud’s phenomenon and are observed in 50% of patients, 15% of the atrial myxoma patients present with hemoptysis which may be due to an infraction or pulmonary oedema.Laboratory studies include raised inflammatory markers including ESR and CRP, leukocytosis and anaemia. Transesophageal echocardiography has better specificity and 100% sensitivity compared to transthoracic echocardiography.Histologic studies demonstrate the presence of lipidic cells embedded in a vascular myxoid stroma. Other investigation modalities include MRI, CT, and nuclear imaging.Conventional treatment of atrial myxoma is surgical removal by median sternotomy. Mini thoracotomy with robotically assisted surgery has been reported, resulting in a shorter length of hospital stay, and it is considered a safe and feasible method for atrial myxoma excision. The investigators did not observe any difference in the quality of life between the two strategies. A case report of total endoscopic robotic resection of a left atrial myxoma in an elderly patient with persistent left superior vena cava also demonstrated the good outcome. No recurrence of myxoma was observed during the 2-year follow-up period if resected completely.Key learning pointsPolymyalgia rheumatica, raised inflammatory markers, malignancy, atrial myxoma, large vessel vasculitis.Conflicts of interestThe authors have declared no conflicts of interest.

Investigating Some Of Blood Parameters In Women With β-Thalassemia

The current study was conducted in the Department of Life Sciences - Faculty of Science - University of Qadisiyah in cooperation with Maternity Hospital and Educational Children and the Center for Hematology in Diwaniyah for the period from 1/10/2017 to 1/4/2018. Fifty (50) samples were taken from women aged 15 to 35 years, and were divided into two groups: 30 women with thalassemia (experimental group) and 20 women without thalassemia (control group). Two (2) milliliter were taken from thalassemia-treated women and 2ml from healthy women for the purpose of conducting blood tests for phytoplankton, blood groups and the level of ferritin in the body. The results of the present study showed a significant decrease (P <0.01) in all blood parameters, hemoglobin, blood corpuscular, corpuscular volume, mean corpuscular hemoglobin in corpuscular and mean corpuscular hemoglobin contraction, compared with control group. Chemo-biological tests like ferritin testing confirmed significant ferritin increase by P<0.01 for the experimental group compared to the control group.

Development and implementation of a quality improvement toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A before-and-after study.

BackgroundIron deficiency (ID) in pregnancy is a common problem that can compromise both maternal and fetal health. Although daily iron supplementation is a simple and effective means of treating ID in pregnancy, ID and ID anemia (IDA) often go unrecognized and untreated due to lack of knowledge of their implications and competing clinical priorities.Methods and findingsIn order to enhance screening and management of ID and IDA in pregnancy, we developed a novel quality-improvement toolkit: ID in pregnancy with maternal iron optimization (IRON MOM), implemented at St. Michael’s Hospital in Toronto, Canada. It included clinical pathways for diagnosis and management, educational resources for clinicians and patients, templated laboratory requisitions, and standardized oral iron prescriptions. To assess the impact of IRON MOM, we retrospectively extracted laboratory data of all women seen in both the obstetrics clinic and the inpatient delivery ward settings from the electronic patient record (EPR) to compare measures pre- and post-implementation of the toolkit: a process measure of the rates of ferritin testing, and outcome measures of the proportion of women with an antenatal (predelivery) hemoglobin value below 100 g/L (anemia), the proportion of women who received a red blood cell (RBC) transfusion during pregnancy, and the proportion of women who received an RBC transfusion immediately following delivery or in the 8-week postpartum period. The pre-intervention period was from January 2012 to December 2016, and the post-intervention period was from January 2017 to December 2017. From the EPR, 1,292 and 2,400 ferritin tests and 16,603 and 3,282 antenatal hemoglobin results were extracted pre- and post-intervention, respectively. One year after implementation of IRON MOM, we found a 10-fold increase in the rate of ferritin testing in the obstetric clinics at our hospital and a lower risk of antenatal hemoglobin values below 100 g/L (pre-intervention 13.5% [95% confidence interval (CI) 13.0%–14.11%]; post-intervention 10.6% [95% CI 9.6%–11.7%], p < 0.0001). In addition, a significantly lower proportion of women received an RBC transfusion during their pregnancy (1.2% pre-intervention versus 0.8% post-intervention, p = 0.0499) or immediately following delivery and in the 8 weeks following (2.3% pre-intervention versus 1.6% post-intervention, p = 0.0214). Limitations of this study include the use of aggregate data extracted from the EPR, and lack of a control group.ConclusionsThe introduction of a standardized toolkit including diagnostic and management pathways as well as other aids increased ferritin testing and decreased the incidence of anemia among women presenting for delivery at our site. This strategy also resulted in reduced proportions of women receiving RBC transfusion during pregnancy and in the first 8 weeks postpartum. The IRON MOM toolkit is a low-tech strategy that could be easily scaled to other settings.

Pediatric Helicobacter Pylori infection prevalence and iron deficiency anemia coincidence among children in North Central Turkey

INTRODUCTION: To estimate Helicobacter Pylori (H.Pylori) prevalence, coincidence of iron deficiency anemia (IDA) and related hematological parameters in children of North Central Turkey. METHODS: Hemoglobin, hematocrit, mean corpuscular volume (n=852); serum iron level (n=175), iron binding capacity (n=175), ferritin (n=197), transferrin saturation (n=254) and 14C urea breath test results (n=1006) were reviewed in children with nonspecific gastrointestinal symptoms. H.Pylori prevalence was determined; hematological parameters were compared in H.Pylori positive and negative patients. RESULTS: Overall H.Pylori prevalence was 46,8%. Hemoglobin and hematocrit values were significantly lower in H. Pylori positive patients (T: 4,014 P: 0,000 for hemoglobin; T: 3,486 P: 0,001 for hematocrit). Although MCV values were lower in H. Pylori positive patients, the difference was not statistically significant.Serum iron levels (T: 2,297 P: 0,023), ferritin levels (T: 2,19 P: 0,03) and transferrin saturations (T: 2,541 P: 0,012) were significantly lower in H.Pylori positive patients. Iron binding capacity was higher in H.Pylori positive patients but this was also not significant. H.Pylori positivity is significantly higher in anemic patients (x²: 23,533 P: 0,000), in patients with low transferrin (x²: 4,948 P: 0,026), low ferritin (x²: 6,96 P: 0,008) and in patients with low ferritin and anemia together (x²: 13,74 P: 0,00). In females and males, anemia was significantly higher in H.Pylori positive patients (x²: 9,033 P: 0,003 and x²: 15,016 P: 0,000 in females and males respectively). DISCUSSION AND CONCLUSION: H.Pylori positivity rate in the pediatric population of North Central Turkey seems to be a median value within the range of yet reported Turkish prevalence. There is an association between H.Pylori and IDA according to the results of a large pediatric population

Iron status and risk factors for iron depletion in a racially/ethnically diverse blood donor population.

The optimal approach for reducing iron depletion (ID) in blood donors may vary depending on biologic or behavioral differences across donors. More than 12,600 successful whole blood donors were enrolled from four US blood centers for ferritin testing. The study population was enriched for racial/ethnic minorities (1605 African American, 1616 Asian, 1023 Hispanic). Subjects completed questionnaires on ID risk factors. Logistic regression identified predictors of absent iron stores (AIS; ferritin <12 ng/mL) and low ferritin (LF; ferritin <26 ng/mL). Across all subjects, 19% had AIS and 42% had LF, with a sharp increase in risk observed with increasing donation intensity and among women a large decrease in risk in those more than 50 years old. When other factors were controlled for, African American and Asian donors showed 20% to 25% decreased risk for AIS compared to non-Hispanic Caucasian donors, while Hispanic donors had 25% higher risk. Daily iron supplementation reduced risk for LF and AIS by 30% to 40%, respectively, while the benefit from less frequent use was lower (7%-19% protection). Regular antacid use was associated with at least 20% increment to risk. Use of oral contraceptives or estrogen in females reduced risk by 16% to 22%, while males who reported supplemental testosterone use had a 50% to 125% greater risk for LF and AIS. This study confirms high prevalence of LF and AIS in US donors and the principal risk factors of age, sex, and donation frequency. Additional demographic and behavioral risk factors of secondary importance might allow for refinement of ID mitigation strategies.

The investigation of chronic diarrhoea: new BSG guidance.

Chronic diarrhoea has an estimated prevalence of about 4–5% in Western populations and is one of the most common reasons for gastroenterology referral.1 There is a myriad of causes for chronic diarrhoea, which can make the investigation and diagnosis of the underlying cause difficult. In 2003, the British Society of Gastroenterology (BSG) released guidelines2 to aid in the investigation of chronic diarrhoea; however, these have since been updated, in April 2018. Below, we provide a brief and focused summary of the new 2018 guidelines1 for primary care, highlight the new changes compared with the 2003 edition, and discuss some limitations of the new guidance. Initial investigations in primary care are aimed at differentiating organic gastrointestinal (GI) disease from functional disease. Routine, screening blood tests are recommended in all patients presenting with chronic diarrhoea, and these include full blood count, ferritin, c-reactive protein, coeliac serology, and thyroid function tests. Faecal calprotectin (FCP) is now recommended as a screening tool to detect inflammatory causes of chronic diarrhoea, and stool cultures remain useful in distinguishing infection from other inflammatory causes of chronic diarrhoea. Faecal immunochemical testing (FIT) is a new method of detecting the presence of blood in faeces and can be used instead of the traditional faecal occult blood test (FOBT) where available. In general, for patients with typical symptoms of functional bowel disease, normal physical examination, and normal screening investigations, a diagnosis of IBS can be made. However, referral should be considered for those with abnormal screening investigations or persistent symptoms that impact the quality of life and do not respond …

0812 The Restless Sleeper: Associations Between Clinical Symptoms, Ferritin Level, And Limb Movements

Iron status is an important aspect of the evaluation of children with restless leg syndrome, periodic limb movement disorder, or clinically restless sleep. While there is clear data in adults to support this relationship, the data in children is less well established. We evaluated possible associations between iron status, clinically symptoms of restless sleep, and polysomnographic-derived limb movements during sleep in a large pediatric sample. This is a retrospective analysis of a single institution sleep program looking at all patients who underwent overnight polysomnogram, had ferritin test within 24 hours of doing the sleep study, and had completed parent-report sleep questionnaire over the course of 1 year. Those with sleep apnea (Central Apnea Index >5/hr or Obstructive Apnea Hypopnea Index >2/hr) were excluded. In addition, children who were taking medications that potentially could affect outcomes of interest were excluded (hypnotics, psychotropic medications, supplemental iron). There were a total of 46 patients who qualified for inclusion. Mean age was 6.7 years (range 0-15 years). Ferritin levels were not significantly different between children with or without six possible parent-endorsed descriptors of restless sleep. Children described as having “repeated kicks of legs” during sleep had a significantly higher single limb movement index (10.1 +/-5.4 vs 6.7 +/- 3.0, p=0.02) and total limb movement index (15.1 +/- 7.3 vs 10.3 +/- 5.7, p=0.04); otherwise there were no significant associations between symptoms and limb movement indices. In this carefully screened sample of children, we found no significant association between ferritin level and any parent-reported symptom of restless sleep or limb movement index. We found that children with parent-reported “repeated kicks of legs” during sleep had increased single limb movement and total limb movement indices. None

Low dose ruxolitinib plus HLH-94 protocol: A potential choice for secondary HLH

Hemophagocytic lymphohistiocytosis (HLH) is an immune-mediated syndrome resulting in cytokine storm. The uncontrolled cytokine storm leads to significant tissue damage and potentially life-threatening multiorgan failure. Conventional first-line treatment for HLH included HLH-94 protocol or HLH-2004 protocol. However, up to 30% of patients do not respond to first-line therapy. We reported 3 cases of secondary HLH/macrophage activation syndrome which were caused by lymphoma (2 cases) and adult-onset still's disease. They received low dose ruxolitinib plus HLH-94 protocol, and had rapid response to treatment without obvious adverse effects. Following the treatment, there was improvement seen in several disease markers, including fever, fibrinogen, serum ferritin, and liver function tests. Our report indicated that treatment with low dose ruxolitinib plus HLH-94 protocol might be a potential choice for secondary HLH, and clinical trials warrants to be further investigated in this treatment regimen.

Elevated risk for iron depletion in high-school age blood donors.

High school students 16 to 18 years-old contribute 10% of the US blood supply. Mitigating iron depletion in these donors is important because they continue to undergo physical and neurocognitive development. Study objectives were to determine the prevalence of iron depletion in 16- to 18-year-old donors and whether their risk for iron depletion was greater than adult donors. Successful, age-eligible donors were enrolled from high school blood drives at two large US blood centers. Plasma ferritin testing was performed with ferritin less than 12 ng/mL as our primary measure of iron depletion and ferritin less than 26 ng/mL a secondary measure. Multivariable repeated-measures logistic regression models evaluated the role of age and other demographic/donation factors. Ferritin was measured from 4265 enrollment donations September to November 2015 and 1954 follow-up donations through May 2016. At enrollment, prevalence of ferritin less than 12 ng/mL in teenagers was 1% in males and 18% in females making their first blood donation, and 8% in males and 33% in females with prior donations. Adjusted odds for ferritin less than 12 ng/mL were 2.1 to 2.8 times greater in 16- to 18-year-olds than in 19- to 49-year-olds, and for ferritin less than 26 ng/mL were 3.3- to 4.7-fold higher in 16- to 18-year-olds. Progression to hemoglobin deferral was twice as likely in 16- to 18-year-old versus 19- to 49-year-old females. Age 16 to 18 years-old is an independent risk factor for iron deficiency in blood donors at any donation frequency. Blood centers should implement alternate eligibility criteria or additional safety measures to protect teenage donors from iron depletion.

Automated Requests for Thyroid-Stimulating Hormone and Ferretin Tests in Young Primary Care Patients with Anorexia as an Intervention to Improve Detection of Underlying Conditions.

To improve clinical laboratory contribution to the treatment of primary care patients with anorexia through automated computerized strategies. We recorded the number of laboratory requests due to anorexia; the demographic data, laboratory values, and presence of pathological values for the applicable patients. In a prospective study, the laboratory information management system (LIMS) automatically added thyroid-stimulating hormone (TSH) and/or ferritin testing when it was not requested by general practitioners for all primary care patients with anorexia who were younger than 16 years. A total of 3562 patients underwent laboratory testing due to anorexia, of whom 47% were younger than 16 years. The tests in which the results most frequently were abnormal were hemoglobin, ferritin, and TSH. TSH results were abnormal in 20% of patients younger than 16 years. Through the intervention, we detected 3 low ferritin values and 7 cases of pathological TSH levels. The LIMS required TSH and ferritin testing in young patients even when not requested, potentially avoiding the adverse effects of iron deficiency and thyroid disorders on neurological development and cognition in those patients.

Perception of doctors in different specialties of iron deficiency and iron deficiency anemia in Algeria in 2016: the SUPFER DZ survey

IntroductionLes méthodes de diagnostic et la prise en charge de la carence martiale et de l'anémie ferriprive en pratique clinique en Algérie restent mal connues.MéthodesEnquête transversale réalisée en 2016 auprès de médecins de différentes spécialités concernés par la prise en charge de l'anémie ferriprive.RésultatsPour l'analyse des données, 349 questionnaires ont été validés (anesthésie/réanimation: 39; gynécologie/obstétrique: 111; oncologie/hématologie: 71; hépato-gastroentérologie: 64; cardiologie: 36; médecine interne: 28). Toutes spécialités confondues, 73% (254/349) des médecins estimaient que l'anémie ferriprive concernait au moins 30% de leur patientèle; 65% (226/349) estimaient que la carence martiale concernait au moins 30% de leur patientèle. La carence martiale était explorée systématiquement par 57% (63/111) des médecins du groupe gynécologie/obstétrique, mais par 11% (26/238) seulement des autres médecins; en effet, 82% (195/238) ne la recherchaient qu'en cas d'anémie. Dans le cadre d'un bilan de carence martiale, l'hémoglobine (Hb) était presque toujours évaluée (89%; 310/349) alors que les examens biologiques qui ciblent directement le métabolisme du fer l'étaient insuffisamment: par 70% (244/349) des médecins pour la ferritine sérique et par seulement 37% (128/349) pour le coefficient de saturation de la transferrine. En cas de carence martiale (avec ou sans anémie), le fer oral était prescrit par 92% (322/349) des médecins et 36% (127/349) prescrivaient du fer injectable en tenant compte essentiellement du taux d'Hb.ConclusionCette enquête montre que la carence martiale semble n'être envisagée que dans le cadre de l'anémie. En particulier, les examens biologiques spécifiques de la carence martiale sont insuffisamment prescrits.

Iron Deficiency Project in Pregnancy: Maternal Iron Optimization (IRON MOM)

BackgroundIron deficiency (ID) is the most common and widespread nutritional deficiency in the world and is found predominantly in women of reproductive age. The prevalence of ID is even higher in pregnancy, as maternal iron requirements increase to accommodate the expansion of maternal red blood cell (RBC) mass, development of the placenta and fetus, and the loss of blood associated with labor and delivery. When ID leads to anemia (IDA), it is associated with preterm delivery, cesarian delivery, RBC transfusions, low birth weight, five minute Apgar score < 7, neonatal intensive care unit admission and long term effects on mental and psychomotor development in the child. Although ID in pregnancy is simple to diagnose and treat, it often goes undiagnosed and untreated, due to low awareness of its implications and multiple competing priorities.ObjectivesOur primary objective was to increase awareness of ID in pregnant women, measured by a process metric which compared the monthly rate of ferritin testing pre- versus post-initiative.Our secondary objective was to decrease the incidence of IDA in pregnant women, measured by comparing the proportion of women to ever have an antepartum hemoglobin (HB) ≥ 100g/L pre- versus post- initiative.MethodsUsing a multidisciplinary and sequential quality improvement approach, we developed the IRON MOM toolkit for use at our institution, St. Michael's Hospital (SMH), Toronto, Canada. The toolkit included educational resources for clinicians and patients, clinical pathways to guide management of ID in pregnancy, adjusted laboratory requisitions and providing standardized iron prescriptions in the prenatal clinic.The initiative was formally reviewed by institutional authorities and was deemed to neither require Research Ethics Board approval nor written informed consent from participants.Data was collected from the electronic patient record to compare pre-intervention data (January 1, 2012 to December 31, 2016) to post-intervention data (January 1, 2017 to December 31, 2017). SAS software was used for statistical analysis. The monthly ferritin rates were calculated by dividing the number of ferritin tests by the number of outpatient HB tests, at each month and year and multiplying by 100. For the proportion of women to have ever had an antepartum HB ≥100g/L, as some women may have been in both the pre and post intervention groups, generalized estimating equations were used, with binomial distribution and logit link, to test for differences between pre and post periods.ResultsIRON MOM was launched at SMH on January 1, 2017. The pre-intervention five year period included 1292 outpatient ferritin tests, and 16,603 antepartum HB values belonging to 15,019 women and the post-intervention one year period included 2400 outpatient ferritin tests and 3282 antepartum HB values belonging to 3280 women.The monthly rate of ferritin testing increased dramatically post-initiative, 81.0 (Standard Deviation [SD] 6.3) compared to 8.4 (SD 4.4) pre-initiative. Please see figure 1 for details.There was a statistically significant increase in the proportion of women to have ever had an antepartum HB ≥ 100g/L, 89.5% (2936/3280) (95% confidence interval (CI) 88.3% to 90.4%) in the post-initiative, compared to 87.8% (13184/15,019)(95%CI 87.2% to 88.3%) in the pre-initiative period (p<0.01).ConclusionsThe IRON MOM toolkit successfully increased awareness of ID in pregnant women. The implementation of educational materials and simple process changes dramatically increased the rate of ferritin testing by almost 10x. Although there were statistically significant increases in the proportion of women with antepartum HB greater than 100g/L, post-IRON MOM, these changes were clinically insignificant. This was expected as this assessment was limited to one year (52 weeks) post intervention, and a full term pregnancy is 40 weeks. Therefore, only the women giving birth in the last 12 weeks of the year would have participated in the initiative throughout their entire pregnancy.We conclude that the practical changes involved in the IRON MOM tool kit have the potential for clinically meaningful impact. Future directions include simplification and digitization of the tool kit, which aim to maximize adherence to the protocols and further empower the pregnant patient. DisclosuresLausman:Ferring: Other: gave a talk.

Prevalence of Iron Deficiency in Pregnancy: A Single Centre Canadian Study

BackgroundIron deficiency (ID) is the most common and widespread nutritional deficiency in both developing and developed countries (WHO, 2001; Mei et al., 2011). Women of child bearing age are at the highest risk, but this risk increases even more during pregnancy. The expansion of blood volume, growth of the fetus and placenta increase demand for iron to approximately 5.0mg/day by the third trimester (Met et al., 2011). Common symptoms of ID during pregnancy include fatigue, shortness of breath, and difficulty concentrating (WHO, 2001). Poor prenatal iron status is associated with diminished cognitive performance, language ability, and motor functions in the child (Tamura et al, 2002). For the mother, it is associated with risk of blood transfusion and post-partum depression. Despite international recommendations and guidelines on the management of ID in pregnancy, it remains a problem of epidemic proportions and is often unrecognized and left untreated.To increase awareness of ID, a quality improvement project, IRON Deficiency project in Pregnancy: Maternal Iron Optimization (IRON MOM) was implemented January 1st, 2017 at St. Michael's Hospital (SMH), in Toronto, Canada. Phase 1 of the project involved adapting lab requisitions and workflow in the obstetrics clinic to incorporate routine measurement of ferritin in week 12, 16 and 28 of pregnancy. As part of the IRON MOM, laboratory requisitions were modified to include ferritin as part of routine screening for all pregnant women.ObjectiveThe primary objective of this study was to assess the prevalence of ID in pregnant women consistently screened for ID after the implementation of the IRON MOM quality improvement project at a tertiary hospital in Toronto, Canada.MethodsAdministrative laboratory data was collected from the electronic medical record system at SMH, Toronto, Canada between January 1 and December 31, 2017. Suboptimal iron stores was defined as serum ferritin between 30-50μg/L. ID was defined as serum ferritin between 15-29μg/L, and severe ID was defined as <15μg/L. Significant anemia was defined as hemoglobin levels <100 g/L. Descriptive statistics were used to calculate proportions. SAS version 9.4 was used to perform the analyses.ResultsIn 2017, 2400 ferritin tests were completed on pregnant women at our institution. A total of 76.8% (1844/2400) of tests demonstrated iron deficiency with a ferritin <30μg/L. Of those, 30.2% (726/2400) had ferritin between 15-29μg/L, and 46.6% (1118/2400) were severely iron deficient with a ferritin <15μg/L (Figure 1). 3282 hemoglobin checks, at delivery, occurred in this same one-year period and 10.5% (345/3282) were significantly anemic (<100 g/L). Of those, 6.2% (204/3282) had hemoglobin levels between 90-99g/L, 2.6% (85/3282) had hemoglobin levels between 80-89g/L, and 1.7% (56/3282) had hemoglobin levels <80g/L.ConclusionWe found an extremely high prevalence of ID in our pregnant patient population. This confirms that ID remains an underappreciated problem, even at a tertiary care centre. Our findings highlight a tremendous gap in awareness, which demands strategies to improve knowledge translation. Future directions include the simplification and digitization of IRON MOM to empower pregnant patients to advocate for their care. DisclosuresLausman:Ferring: Other: gave a talk.