Persistent Anemia Research Articles

Diagnosis and treatment of perioperative anaemia in elective primary hip and knee arthroplasty : Consensus statement of the "Committee for Perioperative Management" of the Working Group for Endoprosthetics

Hip and knee arthroplasty remain risk procedures for bleeding complications. The prevalence of preoperative anaemia prior to elective joint replacement is high. There are no standardized guidelines in Germany for the diagnosis and treatment of perioperative anaemia in elective hip and knee arthroplasty. The aim of this work, initiated by the "Perioperative Management" committee of the German Society for Endoprosthetics (AE), was to develop atreatment recommendation. Asystematic review of relevant publications between 2010 and 2023 was conducted. Medline, the Cochrane Library, existing national and international guidelines, and recommendations from other professional societies were considered. Atotal of 38relevant articles were identified. Questions with clinical relevance were prepared in advance by the committee, and these were answered after studying and evaluating the literature. Finally, arecommendation was determined by expert consensus using the GRADE system. All patients scheduled for elective joint replacement should undergo preoperative diagnostics. Preoperative anaemia is arisk factor for increased mortality and the likelihood of transfusions; therefore, the cause of anaemia should be investigated preoperatively and treated accordingly. The administration of iron should be considered in diagnosed iron deficiency and can be done either orally or intravenously. Oral substitution therapy should be started 3months preoperatively. Intravenous therapy requires less time, causes fewer side effects and should be administered 4weeks preoperatively. Persistent iron deficiency anaemia despite substitution, anaemia due to chronic inflammation and renal anaemia may indicate the need for erythropoietin substitution.

Case of Metastatic Canine Transmissible Venereal Tumor in a Dog: Clinical and Cytological Evaluation

Canine transmissible venereal tumor (TVT) is a naturally occurring, transmissible neoplasm primarily affecting the genitalia in dogs. Though generally benign, it can rarely metastasize to other body parts. This report describes a rare case of metastatic TVT in a 2-year-old female Boerboel, presenting with a large, ulcerated vulvar mass and metastases to the popliteal lymph node and mammary glands. Clinical findings included progressive mass growth, emaciation, and systemic symptoms. Hematological tests revealed non-regenerative anemia and elevated white blood cell count, while cytological examination identified neoplastic round cells with high nucleus-to-cytoplasm ratios and mitotic figures. The dog was treated with vincristine chemotherapy, metronidazole, vitamin C, and a diet supplemented with crude sap extract of Telfairia occidentalis at 120 mg/kg once daily. Significant tumor regression and clinical improvement were observed after four weeks, although persistent anemia and borderline hypoproteinemia were noted. By the fifth week, the mass had notably reduced, and the dog's condition continued to improve, though some hemorrhage remained. This case highlights the rare occurrence of metastatic TVT and underscores the effectiveness of vincristine in treatment, emphasizing the need for prompt diagnosis and management despite its generally low metastatic rate.

Tracheal reconstructive surgery under ECMO for the treatment of congenital tracheal stenosis in the premature infant: case report

BackgroundCongenital tracheal stenosis (CTS) is a rare but life-threatening malformation of the trachea. Surgical reconstruction is the treatment of choice in symptomatic cases which is highly risky and is rarely performed in extremely premature infants. With this, reporting a case of CTS managed by tracheal reconstructive surgery under ECMO in a baby weighing 1.47 kg at 32 + 1 WOG was the first ever case in China.Case presentationA premature newborn with a very low birth weight (VLBW) was admitted to our institute for breathing difficulties, requiring mechanical ventilation, and experienced two unsuccessful attempts of extubation. The team performed tracheal reconstructive surgery supported by ECMO after identifying lower tracheal stenosis through a bronchoscopy examination. One month after the surgery, oxygen support was able to discontinue. The patient's entire hospitalization was incredibly challenging, marked by hemodynamic instability with persistent anemia, and disseminated intravascular coagulation (DIC), which were managed with great care. Despite the difficult stay, a follow-up bronchoscopy revealed no obstruction or tracheal stenosis, leading to a successful discharge.ConclusionAdvancements in diagnostic techniques and innovative management methods have made diagnosing and treating CTS easier, even in premature infants. Our case is the first in China to successfully undergo tracheal reconstructive surgery supported by ECMO, inspiring future achievements in the medical field.

Persistent anaemia and unresolved systemic dysfunction among persons living with HIV infection in Southern Nigeria

Persistent anaemia and unresolved systemic dysfunction among persons living with HIV infection in Southern Nigeria

Danicopan (Voydeya)

Canada’s Drug Agency (CDA-AMC) recommends that Voydeya be reimbursed by public drug plans as an add-on to ravulizumab or eculizumab for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH) who have residual hemolytic anemia due to extravascular hemolysis (EVH) if certain conditions are met. Voydeya should only be covered to treat adult patients with a diagnosis of PNH, who have met the public drug plan reimbursement criteria for initiating complement 5 inhibitor (C5i) treatments (ravulizumab or eculizumab) before receiving C5i treatment, and who have been on a stable dose of C5i treatment for 6 months or more, in addition, patients should also have persistent anemia caused by EVH, and an absolute reticulocyte count of 120 × 109/L or greater. Voydeya should only be reimbursed if prescribed by a hematologist with experience managing PNH. The cost of Voydeya should be negotiated so that Voydeya plus a C5i as a regimen does not exceed the drug program cost of treatment with pegcetacoplan for the treatment of adult patients with PNH who have residual hemolytic anemia due to EVH.

A Case Report of a Suspected Neonatal Alloimmune Thrombocytopenia in a Tertiary Health Institution

Fetal and neonatal alloimmune thrombocytopenia FNAIT is the leading cause of severe thrombocytopenia in the fetus and neonate leading to serious bleeding, intracranial haemorrhage and death and also intracranial haemorrhage in full-term infants. We reported a case of a 33-year-old woman who was delivered of a male neonate via Emergency lower segment Cesarean section CS on account of premature rupture of the membrane with oligo hydramnios at an estimated gestational age EGA of 29 weeks 3 days. Her blood group is O Rhesus D positive, and Genotype HbAA. No known premorbid illness. Her last confinement was of a male child delivered via CS and died within 12 hours of birth. This reported case of suspected FNAIT was a baby received alive after CS with birthweight of 1,060g and APGAR score of 7185 transiently, and was noticed to be bleeding from the mouth and anus shortly after birth. Thereafter, he had thrombocytopenia, persistent anaemia, several apneic attacks, seizures, desaturation and died after 42 hours of life despite all prompt clinical interventions. Autopsy summary includes anaemia, central cyanosis, petechial hemorrhage, diffuse alveolar damage, cerebral edema, acute tubular necrosis, small for gestational age and placental vasculopathy. Conclusion: Fetal and neonatal alloimmune thrombocytopenia is a rare disorder and yet poses a challenging diagnosis and treatment plan in resource-limited centres especially in developing countries. Although the clinical findings of the reported suspected case were not classical as previously reported by other studies, they’re pointers to our curiosity and open to further criticism.

Prevalence of Celiac Disease in Patients with Nutritional Anemia in Western Part of India.

Background: Around 1.6 billion people worldwide are affected by nutritional anemia. A small percentage of nutritional anemia cases are attributed to celiac disease (CeD). However, data on the prevalence of CeD among individuals with nutritional anemia in the Western part of India is scarce. Patients and methods: Individuals with nutritional anemia were prospectively investigated for the presence of CeD through the detection of immunoglobulin A (IgA) antitissue transglutaminase antibodies (anti-tTG Ab). Those who had a positive antibody result proceeded to have an upper gastrointestinal endoscopy, accompanied by a duodenal biopsy. The diagnosis of CeD was confirmed following Indian guidelines. Results: A total of 116 patients, including 96 females, were screened, with a mean age of 37 ± 17.8 years. Among them, 19 patients (16.3%) were positive for IgA anti-tTG antibodies. Fifteen of these antibody-positive patients agreed to undergo a duodenal biopsy, which showed villous abnormalities of modified Marsh grade 2 or higher in 11 cases. The overall seroprevalence of CeD was 16.3%, while the biopsy-confirmed prevalence stood at 9.3%. Moreover, an additional four patients (3.4%) were identified as having potential CeD. Chronic diarrhea and short stature emerged as significant predictors of CeD among patients with nutritional anemia. Conclusion: Even in the Western part of India, approximately one in 10 patients with nutritional anemia have CeD, reflecting similar findings across the country. Consequently, we should screen all patients with nutritional anemia for CeD through antitissue transglutaminase antibody testing. This is especially crucial for those with unexplained, persistent nutritional anemia that does not respond to oral iron therapy.

Causes and Consequences of Persistent Anemia after 6 Months of Antiretroviral Therapy in Tanzania: An Observational Comparative Cohort Study.

Anemia is common among people living with HIV (PLWH), particularly in Africa. Outcomes for PLWH on modern antiretroviral therapy (ART) regimens are not well documented. We conducted an observational study to determine the outcomes and predictors of anemia after ART initiation in Tanzania. We enrolled and followed ART-naïve PLWH and HIV-uninfected individuals at three clinics in Tanzania. We grouped participants into four longitudinal categories based on hemoglobin concentration measured at baseline and 6 months after ART initiation (normal, resolved anemia, incident anemia, and persistent anemia) and followed them for 24 months. There were 991 study participants (494 PLWH, 497 HIV uninfected). After 6 months of ART, 33.9% of PLWH had persistent anemia and 9.9% had incident anemia compared with 12.6% and 9.6% for HIV-uninfected controls. Female sex (adjusted odds ratio [aOR]: 2.62; 95% CI: 1.91-6.75) and low income (aOR: 3.10; 95% CI: 1.36-7.20) were strong predictors of persistent anemia for both PLWH and HIV-uninfected individuals. For PLWH, having a CD4+ T cell count of less than 350 cells/mm3 (aOR: 0.34; 95% Cl: 0.15-0.73) was significantly associated with anemia resolution. Mortality was higher for PLWH who had persistent anemia or incident anemia than for PLWH who had normal hemoglobin or improved anemia (hazard ratio: 4.0, 95% Cl 1.3-12.2). One-third of adults in Tanzania had persistent anemia after 6 months on ART, and persistent anemia was associated with increased mortality. PLWH with persistent or incident anemia after 6 months on modern ART deserve close follow-up, particularly women and low-income adults.

ANA-positive versus ANA-negative Antiphospholipid Antibody-positive Patients: Results from the APS ACTION Clinical Database and Repository.

This study focused on the prevalence and impact of antinuclear antibodies (ANA) in antiphospholipid antibody (aPL)-positive patients without concomitant systemic autoimmune rheumatic diseases (SARDs). Data from aPL-positive patients with or without Revised Sapporo APS classification criteria were retrieved from the APS ACTION Registry. Patients with concomitant SARDs were excluded. 430 aPL-positive patients were included in the analysis, 56% ANA-positive and 44% negative. ANA positivity was significantly associated with history of hematologic manifestations (persistent autoimmune hemolytic anaemia, thrombocytopenia, leukopenia and/or lymphopenia) (16% of ANA-positive vs 7% of ANA-negative, p= 0.006). Triple aPL-positivity was more frequent in the ANA-positive subgroup (p= 0.02), along with low baseline C3 and C4 levels (p= 0.05 and p= 0.009, respectively), and higher frequency for extractable nuclear antigens (ENA). Among aPL-positive patients with no APS classification, ANA-positive patients showed a higher rate of arthritis (p= 0.006). Among female patients who have experienced at least one pregnancy, 113 were ANA-positive and 96 were ANA-negative; ANA-negative patients had a higher number of pregnancies (p= 0.018), and number of live births (p= 0.014). A wider proportion of ANA-positive patients were treated with hydroxychloroquine (HCQ) (p< 0.001). When we analysed aPL-positive patients with no other SARDs, ANA status was not associated with thrombosis or pregnancy morbidity. Interestingly, ANA-positive patients showed higher rates of systemic autoimmune features, including hematologic manifestations, multiple aPL positivity, lower complement levels, ENA positivity, and joint involvement, and were more often treated with HCQ. Finally, aPL-positive subjects who were ANA-negative had a higher rate of pregnancies and live births.

Comprehensive evaluation and management of chronic gastritis in a dog: A case report

Gastric ulcer is a significant clinical issue in dogs, with higher prevalence in mature animals and often occurs secondary to systemic diseases such as hepatic or renal disorders, Addison’s disease or shock. This case report highlights a four-and-a-half-year-old intact male Rottweiler presented with persistent vomiting, anorexia, abdominal pain and anemia. Diagnostic imaging, including radiography, ultrasonography and endoscopy, revealed gastric ulceration and the presence of radiopaque lead pellets in the pyloric region of the stomach. Histopathological examination confirmed extensive gastric mucosal damage.Treatment included the elimination of lead, fluid therapy and administration of proton pump inhibitors, antibiotics and mucosal protectants. Incorporating psyllium husk into the diet helped to enhance lead excretion. Follow-up imaging after two weeks showed absence of lead pellets and normal gastric mucosa. This case underscores the importance of comprehensive diagnostic and therapeutic approaches for chronic gastric ulcers in dogs, emphasising the role of multimodal imaging and targeted treatment strategies. Keywords: Dog, gastric ulcers, diagnostics, therapeutics

Cost-effectiveness of iptacopan for paroxysmal nocturnal hemoglobinuria

AbstractIptacopan, a novel oral factor B inhibitor, recently obtained US Food and Drug Administration approval for treating paroxysmal nocturnal hemoglobinuria, a rare blood disorder characterized by persistent complement-mediated hemolytic anemia. The standard-of-care (SOC) has traditionally relied on complement C5 inhibitors eculizumab and ravulizumab, which are limited by persistent anemia from extravascular hemolysis and requirement for intravenous infusion. Recent publication of phase 3 studies in this arena reinforces iptacopan as an effective anticomplement monotherapy compared with SOC. Given ongoing price negotiations and limited literature showing its cost-ineffectiveness in the anti-C5–treated population, we conducted a comprehensive cost-effectiveness analysis of iptacopan monotherapy in anti-C5–treated patients from the societal perspective, as compared with C5 inhibition. The primary outcomes were the incremental net monetary benefit across a lifetime horizon and the cost-effective maximum monthly threshold price of iptacopan monotherapy compared with the SOC. The secondary outcome was time saved for patients and nurses with the use of oral iptacopan therapy. Iptacopan monotherapy and SOC accrued 12.6 and 10.8 quality-adjusted life-years at costs of $9.52 million and $13.5 million, respectively. Iptacopan monotherapy remained cost saving across extensive sensitivity and all scenario analyses, including alternative parameterization for anemia resolution and aggregated individual-level utilities and transition probability matrix. Across all probabilistic sensitivity analyses, iptacopan monotherapy was favored over SOC in 100% of 10 000 Monte Carlo iterations. Cost-saving thresholds for iptacopan vs anti-C5 are ∼1.1, 1.4, and 1.4 in Brazil, Japan, and the United States, respectively. Iptacopan monotherapy can improve quality-adjusted life expectancy for patients while saving health care costs across jurisdictions.

Unmasking Celiac Disease: A Case of Refractory Iron Deficiency Anemia in an Adolescent Girl

Abstract This case report details the clinical journey of a 16-year-old girl who presented with persistent iron deficiency anemia (IDA) and poor growth since childhood. Despite prior treatments, her condition did not improve, leading to further investigation. Comprehensive physical examination and laboratory tests revealed severe microcytic hypochromic anemia. Subsequent evaluations, including serological tests and a duodenal biopsy, confirmed the diagnosis of celiac disease (CD). The girl was started on a strict gluten-free diet along with iron, folic acid, and vitamin D3 supplementation, resulting in significant clinical improvement. This case underscores the importance of considering CD as a differential diagnosis in patients with refractory IDA. It highlights the need for early recognition and appropriate management.

Reduced Rate of Anemia after Transcatheter Aortic Valve Replacement.

Background/Objectives: We sought to evaluate changes in hemoglobin level and renal function in patients 5-12 months after transcatheter aortic valve replacement (TAVR), and to examine possible relationships between these changes. Anemia is common in older people with severe aortic stenosis (AS). The two most common etiologies for anemia in this population are iron deficiency due to gastrointestinal blood loss and renal failure. Angiodysplasia in the gastrointestinal system is a feature of AS syndrome. Methods: We collected clinical data, including hemoglobin level and renal function before and 5-12 months after TAVR in 315 consecutive patients. To examine whether calculated clinical predictors such as EuroScore 2 are associated with the persistence of anemia after TAVR, we performed multivariable correlation analysis with post-TAVR anemia as the dependent variable. Results: The mean hemoglobin level increased significantly (from 11.76 to 12.16 g/dL, p < 0.0001) 5-12 months after TAVR, and the number of patients with anemia decreased significantly (from 67.5% to 53.9%, p < 0.0001). At 5-12 months following TAVR, a small reduction in estimated glomerular filtration rate was observed (from 60.05 ± 24.1 to 58.30 ± 24.50 mL/min, p = 0.024). The multivariable correlation analysis did not identify clinical predictors of persistent anemia. Conclusions: A significant increase in hemoglobin was observed 5-12 months after TAVR, despite a reduction in renal function. Our findings imply that gastrointestinal blood loss, which occurs in patients with severe AS, is significantly reduced following TAVR.

The Impact of Health Behaviors on Iron Supplementation Adherence and Anemia Prevalence among Pregnant Women: Evidence from a Primary Care Setting in Aceh Tengah, Indonesia

Anemia during pregnancy remains a significant global health concern, particularly in developing countries like Indonesia. However, adherence to iron supplementation programs is often suboptimal, leading to persistent anemia and adverse maternal and neonatal outcomes. This study aimed to investigate the relationship between health behaviors (knowledge, attitudes, and practices) and adherence to iron supplementation among pregnant women in a primary care setting in Aceh Tengah, Indonesia. Additionally, we explored the impact of these factors on anemia prevalence. A cross-sectional study was conducted at the Pegasing Community Health Center in Aceh Tengah, Indonesia. Pregnant women diagnosed with anemia were recruited, and data were collected using questionnaires assessing their knowledge, attitudes, and practices regarding iron supplementation. Hemoglobin levels were measured to determine anemia status. Statistical analyses were performed to examine the relationships between health behaviors, adherence, and anemia prevalence. A total of 59 pregnant women with anemia participated in the study. Adherence to iron supplementation was suboptimal, with 59.3% reporting poor adherence. Knowledge about iron supplementation was generally good (76.3%), but attitudes and practices were less favorable (30.5% and 27.1%, respectively). Statistical analyses revealed a significant association between attitudes and practices related to iron supplementation and adherence. Furthermore, poor adherence was linked to a higher prevalence of anemia. In conclusion, healthy behaviors, particularly attitudes and practices, play a crucial role in iron supplementation adherence among pregnant women in Aceh Tengah, Indonesia. Interventions targeting these behaviors are essential to improve adherence and reduce the burden of anemia in this population.

Majeed syndrome: first description in a patient of central-European ancestry.

We present the first case of a Majeed syndrome in a girl of central-European ancestry. : Patient's medical records were reviewed. A NGS panel for autoinflammatory diseases was performed and the mutation was confirmed by Sanger analysis. Freshly isolated monocytes were activated with LPS +/- ATP. The concentration of inflammatory cytokines was assessed in monocytes supernatants. A 2-year-old girl presented with pain in the lower limbs, increase of acute phase reactants and persistent microcytic anaemia. The MRI showed bilateral STIR hyper-intensity of the spongy osseous tissue of femur, tibia, radius, ulna, and astragalus. Bone marrow analysis revealed increased trilinear cellularity with signs of dyserythropoietic anaemia. NGS panel detected the presence of two novel compound heterozygous mutations in the LPIN2 gene, confirmed by Sanger analysis. Treatment with anakinra was started with a prompt resolution of the clinical picture. Increased kinetics and concentration of IL-1β was observed in the patient's monocytes compared with healthy controls, with a marked drop following the start of therapy. About six months after the start of the therapy, resolution of MRI findings, microcytic anaemia and dyserythropoiesis at bone marrow aspirate was observed. We describe the first case of Majeed syndrome in a patient of central-European ancestry. The functional test on circulating monocytes before and after therapy with anakinra confirmed pathogenicity of the mutation and the role of LPIN2 in the NLRP3 inflammasome activation. Anti-IL1 agents were effective, leading not only to the resolution of bone lesion but also to an improvement of dyserythropoiesis.

Особливості перебігу хронічної хвороби нирок у пацієнтів з артеріальною гіпертензією, цукровим діабетом та хронічним гломерулонефритом

Chronic kidney disease (CKD), especially its terminal stage, is a serious problem in modern medicine. There are certain features of the course of CKD in patients with arterial hypertension (AH), diabetes mellitus (DM), and chronic glomerulonephritis (CGN). The purpose of the study was to study the course of CKD against the background of hypertension, diabetes and chronic hypertension based on clinical and laboratory examination data to assess the severity of the patients' condition. Materials and methods. 86 patients with stage V chronic renal failure (CKD) were examined, who were divided into 3 groups depending on the existing concomitant disease. Group 1 (n – 35) included patients with CKD and hypertension, group 2 (n – 28) – patients with CKD and diabetes, and group 3 (n – 23) – patients with CKD and CGN. Anthropometric, general clinical, laboratory and instrumental research methods were performed on all patients. Research results and their discussion. Analyzing the data of a general blood test, 100 % of patients in all three groups had a decrease in hemoglobin and erythrocyte levels. A significant decrease in the level of albumin (p &lt; 0.05) and an increase in the levels of urea (p &lt; 0.001) and creatinine (p &lt; 0.001) were also found, which indicated a pronounced decrease in kidney function and significant kidney damage. Analyzing the results of the ionic composition of the blood, a significant increase in the levels of phosphorus and parathyroid hormone was found in patients of the III group (CNN and CGN). Conclusions: 1. In all groups of patients with CKD of the V degree in combination with concomitant hypertension, diabetes mellitus or CGN, persistent anemia was noted, which was manifested by a progressive drop in hemoglobin to the levels of 86.22 ± 3.61 g/l, 83.89 ± 3.06 g/l and 83.22 ± 3.49 g/l, respectively. 2. In such patients, a pronounced decrease in kidney function was noted, which was manifested by a delay in the release of the products of protein metabolism from the blood due to a decrease in the levels of albumin (p &lt; 0.05), a significant increase in the levels of urea (p &lt; 0.001), creatinine (p &lt; 0.001) and a decrease glomerular filtration rate. 3. In the group of patients with a combination of CKD stage V and CGN, a significant increase in phosphorus and parathyroid hormone levels was found (p &lt; 0.01). Such an increase in the level of parathyroid hormone in blood serum may be associated with a drop in the level of calcium in the blood of such patients and the subsequent progressive increase in the level of inorganic phosphate and the development of hyperphosphatemia.

Role of capsule endoscopy and double-balloon enteroscopy in the management of adult patients with coeliac disease and persisting symptoms

BackgroundSmall bowel capsule endoscopy (CE) and double-balloon enteroscopy (DBE) are recommended for the management of patients with nonresponsive or refractory coeliac disease (CD). However, there is a paucity of data regarding the clinical profiles and outcomes of patients undergoing these investigations. MethodsWe conducted a retrospective analysis of two databases of adult patients with CD who underwent CE and/or DBE between 2017 and 2022 at the National Centre for Refractory CD in England. Patient demographic, clinical and endoscopic data were collected, and clinically relevant outcomes were reported. ResultsA total of 132 patients (median age 53 years, 64.4 % female) underwent 146 CEs and 25 DBEs. The most common symptoms were diarrhoea (51.5 %), abdominal pain (37.8 %), bloating (34.8 %), and weight loss (29.5 %). The overall detection rate of CE and DBE was 87.6 % and 92 %, respectively. Following CE and DBE, 14 patients (10.6 %) were diagnosed with CD-related complications such as ulcerative jejunitis, strictures and malignancy. Seven patients (5.3 %) died during follow-up, with five of these deaths directly attributed to CD. Older age, weight loss and anaemia were associated with poor outcomes. ConclusionsThe sequential approach of CE and DBE identified CD-related complications in almost 1 in 10 patients with nonresponsive or refractory CD. Older patients with persistent villous atrophy, weight loss and anaemia require close monitoring to help with the early diagnosis and management of complications.

Breast milk induced immune haemolytic disease of newborn due to anti-c: A case report

BackgroundHemolytic disease of fetus and newborn is a major risk factor for anemia and hyperbilirubinemia in newborns. Early identification and diagnosis can significantly improve neonatal health. Case reportThis report documents a case of hemolytic disease of fetus and newborn presenting as persistent neonatal anemia requiring frequent transfusion support. The underlying cause was determined to be the passive acquisition of hemolytic alloantibodies (anti-c) via breast milk. ConclusionImportance of antenatal screening for red cell antibodies is gradually being recognized and adopted in developing countries to minimize the burden of HDFN. Breast milk should be considered as a potential source of hemolysing alloantibodies in newborns and may require evaluation in mothers with alloantibodies in her serum.

Exploring Barriers to Obstetric Care: A Case Report on High-Risk Pregnancy in a Limited-resource Primary Care Setting in West Bengal, India

Barriers to obstetric care have been under-researched in the Indian context, especially in limited-resource primary care settings. This case study seeks to unravel the barriers that lead to the high-risk pregnancy status of a 26-year-old second gravida, parity one pregnant mother residing in a rural area of West Bengal, India, in her 38 weeks of gestation with several risk factors. The factors that complicate the case include previous history of low birth weight delivery through cesarean section 4 years back, persistent anemia (Hemoglobin &lt;10 g/dL), lately diagnosed hypothyroidism during the third trimester, and suboptimal weight gain of only 6 kg during the pregnancy (significantly below the recommended 9–11 kg gain) posing risks to both the mother and fetus. Ishikawa’s fishbone diagram has been used to illustrate the various categories and factors contributing to barriers to maternal care. Screening for risk factors, addressing the barriers, and timely case management and follow-up could improve fetomaternal health outcome.

Two-step versus three-step proctocolectomy for ulcerative colitis: a comparative study on nutritional status, immunosuppressive therapy, and long-term outcome.

Despite novel medical therapies, rates of surgery in ulcerative colitis remain relevant. While various surgical approaches for multistep proctocolectomy are available, overall evidence is low and robust recommendations are lacking for individual procedures especially in case of refractory inflammation and signs of malnutrition. All patients who received multistep proctocolectomy between 2010 and 2021 for ulcerative colitis were evaluated and divided into two groups (two-step/2-IPAA [ileal pouch-anal anastomosis] versus three-step/3-IPAA proctocolectomy). Patient characteristics as well as short- and long-outcomes were individually analyzed. Surgical techniques were explained in detail. Fifty patients were included in the study with 27 patients receiving 2-IPAA and 23 patients 3-IPAA. Rates of postoperative complications were comparable for both groups. While patients receiving 2-IPAA were more often suffering from malignancy, 3-IPAA resulted in a significant increase of hemoglobin and albumin levels as well as a reduction of immunosuppressive medication. Rates of stoma reversal trended to be reduced for 3-IPAA compared to 2-IPAA (52.2% vs. 77.8%, p = 0.06). Three-step proctocolectomy with creation of sigmoidostomy is a safe procedure and reasonable surgical approach in patients with preoperatively high dosages of immunosuppressive medication or risk factors such as persistent active inflammation and anemia.