Preoperative anemia management with intravenous iron: a systematic review

Background Iron deficiency anemia is a common condition in patients presenting for surgery, but despite its negative health impacts, the condition remains frequently unmanaged. Optimizing the patient's own red cell mass should be addressed in the preoperative period. Intravenous iron has been advocated as an effective treatment modality. Objectives The objective of this systematic review was to critically appraise and synthesize the best available evidence related to the effectiveness and economic aspects of intravenous iron administration on the correction of iron deficiency anemia in the preoperative period. Inclusion criteria Types of participants Adult patients 18 years of age and older receiving intravenous iron compared with those taking iron orally, and those who were not on iron or were transfused with red blood cells for the correction of anemia. Studies assessing the economic aspects of anemia management were also considered. Types of intervention(s)/phenomena of interest The quantitative component of the review considered studies that evaluated the management of anemia with iron infusions compared to oral iron treatment alone, oral iron in combination with erythropoietin, erythropoietin alone or hemoglobin correction with blood transfusion. The economic component of this review considered studies that evaluated the costs and benefits of iron infusions compared to oral iron treatment or hemoglobin correction with blood transfusion for the treatment of preoperative anemia. Types of studies The quantitative component of the review considered any experimental study design including randomized controlled trials (RCTs), non-RCTs and quasi-experimental studies for inclusion. The economic component of the review considered cost effectiveness, cost utility and cost benefit studies for inclusion. Types of outcomes The quantitative component of this review considered studies that reported on the impact of intravenous iron administration on: hemoglobin levels, red blood cell transfusion, length of stay in hospital, rate of readmission within 30 days of discharge, incidence of transfusion-related complications and changes in functional outcomes. The economic component of the review focused on cost benefits resulting from intravenous iron administration. Search strategy The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. Studies published in English, German, Italian and Dutch from 2001 until December 2012 were considered for inclusion in this review. Methodological quality The studies were independently assessed by two reviewers using standardized critical appraisal instruments from the Joanna Briggs Institute. Data collection Quantitative data was extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute, specifically the Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Economic data was extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute Analysis of Cost, Technology and Utilisation Assessment and Review Instrument (JBI-ACTUARI). Data synthesis This review set out to conduct both meta-analyses of the findings of effectiveness studies using JBI-MAStARI and pooling of economic findings using JBI-ACTUARI. Because of the number of studies found, this was not possible and the findings are therefore presented in tabular or narrative form. Results The quantitative component of the review identified two RCTs for inclusion with one of the trials favoring intravenous iron over oral iron for anemia correction. Only a subgroup could be included from the second trial and the results were inconclusive. Data was heterogeneous and did not allow a meta-analysis. The search for the economic component of the review revealed no examination of the cost effectiveness of preoperative correction of iron deficiency anemia with intravenous iron. Conclusions The review found insufficient data to make firm conclusions about the effectiveness of preoperative intravenous iron administration for the correction of anemia. Neither could we establish firm conclusions on the potential cost savings due to intravenous iron supplementation.Bernd Froessler, Catalin Tufanaru, Allan Cyna, Alan Pearso

Hypnosis Antenatal Training for Childbirth (HATCh): a randomised controlled trial [NCT00282204]

BACKGROUND: Although medical interventions play an important role in preserving lives and maternal comfort they have become increasingly routine in normal childbirth. This may increase the risk of associated complications and a less satisfactory birth experience. Antenatal hypnosis is associated with a reduced need for pharmacological interventions during childbirth. This trial seeks to determine the efficacy or otherwise of antenatal group hypnosis preparation for childbirth in late pregnancy. METHODS/DESIGN: A single centre, randomised controlled trial using a 3 arm parallel group design in the largest tertiary maternity unit in South Australia. Group 1 participants receive antenatal hypnosis training in preparation for childbirth administered by a qualified hypnotherapist with the use of an audio compact disc on hypnosis for re-enforcement; Group 2 consists of antenatal hypnosis training in preparation for childbirth using an audio compact disc on hypnosis administered by a nurse with no training in hypnotherapy; Group 3 participants continue with their usual preparation for childbirth with no additional intervention. Women > 34 and < 39 weeks gestation, planning a vaginal birth, not in active labour, with a singleton, viable fetus of vertex presentation, are eligible to participate. Allocation concealment is achieved using telephone randomisation. Participants assigned to hypnosis groups commence hypnosis training as near as possible to 37 weeks gestation. Treatment allocations are concealed from treating obstetricians, anaesthetists, midwives and those personnel collecting and analysing data. Our sample size of 135 women/group gives the study 80% power to detect a clinically relevant fall of 20% in the number of women requiring pharmacological analgesia – the primary endpoint. We estimate that approximately 5–10% of women will deliver prior to receiving their allocated intervention. We plan to recruit 150 women/group and perform sequential interim analyses when 150 and 300 participants have been recruited. All participant data will be analysed, by a researcher blinded to treatment allocation, according to the "Intention to treat" principle with comprehensive pre-planned cost- benefit and subgroup analyses. DISCUSSION: If effective, hypnosis would be a simple, inexpensive way to improve the childbirth experience, reduce complications associated with pharmacological interventions, yield cost savings in maternity care, and this trial will provide evidence to guide clinical practice

Regional block versus general anaesthesia for caesarean section and neonatal outcomes: a population-based study

<p>Abstract</p> <p>Background</p> <p>Anaesthesia guidelines recommend regional anaesthesia for most caesarean sections due to the risk of failed intubation and aspiration with general anaesthesia. However, general anaesthesia is considered to be safe for the foetus, based on limited evidence, and is still used for caesarean sections.</p> <p>Methods</p> <p>Cohorts of caesarean sections by indication (that is, planned repeat caesarean section, failure to progress, foetal distress) were selected from the period 1998 to 2004 (<it>N </it>= 50,806). Deliveries performed under general anaesthesia were compared with those performed under spinal or epidural, for the outcomes of neonatal intubation and 5-minute Apgar (Apgar5) <7.</p> <p>Results</p> <p>The risk of adverse outcomes was increased for caesarean sections under general anaesthesia for all three indications and across all levels of hospital. The relative risks were largest for low-risk planned repeat caesarean deliveries: resuscitation with intubation relative risk was 12.8 (95% confidence interval 7.6, 21.7), and Apgar5 <7 relative risk was 13.4 (95% confidence interval 9.2, 19.4). The largest absolute increase in risk was for unplanned caesareans due to foetal distress: there were five extra intubations per 100 deliveries and six extra Apgar5 <7 per 100 deliveries.</p> <p>Conclusion</p> <p>The infants most affected by general anaesthesia were those already compromised <it>in utero</it>, as evidenced by foetal distress. The increased rate of adverse neonatal outcomes should be weighed up when general anaesthesia is under consideration.</p

A multidisciplinary program of preparation for childbirth and motherhood: maternal anxiety and perinatal outcomes

Background: To study maternal anxiety and perinatal outcomes in pregnant women submitted to a Multidisciplinary Program for Childbirth and Motherhood Preparation (MPCM).Methods: This is a not randomized controlled trial on 67 nulliparous pregnant women divided into two groups according to participation (MPCM Group; n = 38) or not (Control Group; n = 29) in MPCM. the program consisted of 10 meetings (between the 18th and the 38th gestational week) during which educational, physiotherapeutic and interaction activities were developed. Anxiety was quantified at the beginning and at the end of the gestational period by the Trace-State Anxiety Inventory (STAI).Results: Initial maternal anxiety was equivalent between the groups. At the end of the gestational period, it was observed that anxiety levels increased in the Control Group and were maintained in the MPCM Group. A higher occurrence of vaginal deliveries (83.8%) and hospital discharge of three-day-older newborns (81.6%) as a result of MPCM was also significant. Levels of state-anxiety at the end of pregnancy showed a negative correlation with vaginal delivery, gestational age, birth weight and Apgar index at the first minute and positive correlation with the hospital period remaining of the newborns.Conclusion: in the study conditions, MPCM was associated with lower levels of maternal anxiety, a larger number of vaginal deliveries and shorter hospitalization time of newborns. It was not related to adverse perinatal outcomes.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Univ Estadual Paulista, Botucatu Sch Med, Dept Neurol Psychol & Psychiat, Botucatu, SP, BrazilUniv Estadual Paulista, Botucatu Sch Med, Dept Gynecol & Obstet, Botucatu, SP, BrazilUniv Sagrado Coracao, Dept Hlth Sci, Physiotherapy Sch, Bauru, BrazilSão Paulo Fed Univ Unifesp, Dept Hlth Sci, Phys Therapy Program, Santos, BrazilSão Paulo Fed Univ Unifesp, Dept Hlth Sci, Phys Therapy Program, Santos, BrazilWeb of Scienc

Interaction of hyperalgesia and sensory loss in complex regional pain syndrome type I (CRPS I)

Sensory abnormalities are a key feature of Complex Regional Pain Syndrome (CRPS). In order to characterise these changes in patients suffering from acute or chronic CRPS I, we used Quantitative Sensory Testing (QST) in comparison to an age and gender matched control group

Rare mutations in N-methyl-D-aspartate glutamate receptors in autism spectrum disorders and schizophrenia

Pharmacological, genetic and expression studies implicate N-methyl-D-aspartate (NMDA) receptor hypofunction in schizophrenia (SCZ). Similarly, several lines of evidence suggest that autism spectrum disorders (ASD) could be due to an imbalance between excitatory and inhibitory neurotransmission. As part of a project aimed at exploring rare and/or de novo mutations in neurodevelopmental disorders, we have sequenced the seven genes encoding for NMDA receptor subunits (NMDARs) in a large cohort of individuals affected with SCZ or ASD (n=429 and 428, respectively), parents of these subjects and controls (n=568). Here, we identified two de novo mutations in patients with sporadic SCZ in GRIN2A and one de novo mutation in GRIN2B in a patient with ASD. Truncating mutations in GRIN2C, GRIN3A and GRIN3B were identified in both subjects and controls, but no truncating mutations were found in the GRIN1, GRIN2A, GRIN2B and GRIN2D genes, both in patients and controls, suggesting that these subunits are critical for neurodevelopment. The present results support the hypothesis that rare de novo mutations in GRIN2A or GRIN2B can be associated with cases of sporadic SCZ or ASD, just as it has recently been described for the related neurodevelopmental disease intellectual disability. The influence of genetic variants appears different, depending on NMDAR subunits. Functional compensation could occur to counteract the loss of one allele in GRIN2C and GRIN3 family genes, whereas GRIN1, GRIN2A, GRIN2B and GRIN2D appear instrumental to normal brain development and function

Upon impact: the fate of adhering <i>Pseudomonas fluorescens</i> cells during Nanofiltration

Nanofiltration (NF) is a high-pressure membrane filtration process increasingly applied in drinking water treatment and water reuse processes. NF typically rejects divalent salts, organic matter, and micropollutants. However, the efficiency of NF is adversely affected by membrane biofouling, during which microorganisms adhere to the membrane and proliferate to create a biofilm. Here we show that adhered Pseudomonas fluorescens cells under high permeate flux conditions are met with high fluid shear and convective fluxes at the membrane-liquid interface, resulting in their structural damage and collapse. These results were confirmed by fluorescent staining, flow cytometry, and scanning electron microscopy. This present study offers a 'first-glimpse' of cell damage and death during the initial phases of bacterial adhesion to NF membranes and raises a key question about the role of this observed phenomena during early-stage biofilm formation under permeate flux and cross-flow conditions.European Research Council (ERC

A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications

BackgroundThere is a need for robust, clearly defined, patient-relevant outcome measures for use in randomised trials in perioperative medicine. Our objective was to establish standard outcome measures for postoperative pulmonary complications research

Nitrogen losses as affected by addition of water chalk suspension to the slurry

Przeprowadzone badania wykazały, że straty azotu z gnojowicy trzody chlewnej zależą od temperatury, osiągając po 16 dniowej inkubacji 16% i 48%, odpowiednio w t = 10°C i 18°C. Wodna zawiesina kredy, dodana do gnojowicy, w dawce 160 cm3/l, pozwoliła zmniejszyć straty, odpowiednio do 2% i 20%. Ochronne działanie kredy można wytłumaczyć wystąpieniem serii procesów zdefiniowanych jako efekt zwrotny hydrolizy węglanu wapnia.Conducted study revealed that the losses of total nitrogen (N1) from pig slurry depend on the temperature, reaching after 16 days of incubation 16% and 48% at t = 10 and 18 deg C, respectively. Water chalk suspension added to pig slurry at the rate of 160 cm3/l enabled to reduce the total nitrogen losses down to 2% and 20%, respectively. The protective effect of this additive may be explained by the occurrence of a series of processes defined as the turning effect of calcium carbonate hydrolysis