Dietary supplement use and nosebleeds in hereditary haemorrhagic telangiectasia - an observational study.

Understanding potential provocations of haemorrhage is important in a range of clinical settings, and particularly for people with abnormal vasculature. Patients with hereditary haemorrhagic telangiectasia (HHT) can report haemorrhage from nasal telangiectasia in real time, and suggested dietary factors may precipitate nosebleeds. To examine further, nosebleed severity, dietary supplement use, and blood indices were evaluated in an unselected group of 50 HHT patients recruited from a specialist UK service. Using the validated Epistaxis Severity Score, nosebleed severity ranged from 0 to 9.1 out of 10 (median 3.9). Using a Food Frequency Questionnaire, 24/50 (48%) participants reported use of dietary supplements in the previous year. A third (18/50; 36%) had used self prescribed, non-iron containing dietary supplements, ingesting between 1 and 3 different supplements each day. Eight (16%) used fish oils. Despite having more severe epistaxis (p = 0.012), the 12 iron supplement users had higher serum iron concentrations, and were able to maintain their red blood cell indices. In contrast, there was no evident benefit for the participants using non iron supplements. Furthermore, platelet counts and serum fibrinogen tended to be lower in fish oil/supplement users, and one fish oil user demonstrated reduced in vitro platelet aggregation. In conclusion, in this small study, a third of HHT patients used non-iron dietary supplements, and one in six ingested fish oils, unaware of their known anti-platelet activity. The scale of use, and potential of these "natural health supplements" to exacerbate nosebleeds has not been appreciated previously in HHT

7-day weighed food diaries suggest patients with hereditary hemorrhagic telangiectasia may spontaneously modify their diet to avoid nosebleed precipitants

Hereditary hemorrhagic telangiectasia (HHT) poses substantial burdens due to nosebleeds and iron deficiency resulting from recurrent hemorrhagic iron losses. Recent studies by our group found surprising links between HHT nosebleeds and certain food groups. In this letter, we report 7-day weighed food diary assessments of an unselected group of 25 UK patients with HHT whose nosebleeds ranged from mild to severe (median epistaxis severity score 4.66, range 0.89– 9.11). The diaries provide evidence that food items most commonly reported to provoke nosebleeds were ingested by fewer HHT patients, compared to food items less commonly reported to provoke nosebleeds (chi-squared p <0.001)

Arterial oxygen content is precisely maintained by graded erythrocytotic responses in settings of high/normal serum iron levels, and predicts exercise capacity: an observational study of hypoxaemic patients with pulmonary arteriovenous malformations.

Oxygen, haemoglobin and cardiac output are integrated components of oxygen transport: each gram of haemoglobin transports 1.34 mls of oxygen in the blood. Low arterial partial pressure of oxygen (PaO2), and haemoglobin saturation (SaO2), are the indices used in clinical assessments, and usually result from low inspired oxygen concentrations, or alveolar/airways disease. Our objective was to examine low blood oxygen/haemoglobin relationships in chronically compensated states without concurrent hypoxic pulmonary vasoreactivity.165 consecutive unselected patients with pulmonary arteriovenous malformations were studied, in 98 cases, pre/post embolisation treatment. 159 (96%) had hereditary haemorrhagic telangiectasia. Arterial oxygen content was calculated by SaO2 x haemoglobin x 1.34/100.There was wide variation in SaO2 on air (78.5-99, median 95)% but due to secondary erythrocytosis and resultant polycythaemia, SaO2 explained only 0.1% of the variance in arterial oxygen content per unit blood volume. Secondary erythrocytosis was achievable with low iron stores, but only if serum iron was high-normal: Low serum iron levels were associated with reduced haemoglobin per erythrocyte, and overall arterial oxygen content was lower in iron deficient patients (median 16.0 [IQR 14.9, 17.4]mls/dL compared to 18.8 [IQR 17.4, 20.1]mls/dL, p<0.0001). Exercise tolerance appeared unrelated to SaO2 but was significantly worse in patients with lower oxygen content (p<0.0001). A pre-defined athletic group had higher Hb:SaO2 and serum iron:ferritin ratios than non-athletes with normal exercise capacity. PAVM embolisation increased SaO2, but arterial oxygen content was precisely restored by a subsequent fall in haemoglobin: 86 (87.8%) patients reported no change in exercise tolerance at post-embolisation follow-up.Haemoglobin and oxygen measurements in isolation do not indicate the more physiologically relevant oxygen content per unit blood volume. This can be maintained for SaO2 ≥78.5%, and resets to the same arterial oxygen content after correction of hypoxaemia. Serum iron concentrations, not ferritin, seem to predict more successful polycythaemic responses

Ischaemic strokes in patients with pulmonary arteriovenous malformations and hereditary hemorrhagic telangiectasia: associations with iron deficiency and platelets.

<div><p>Background</p><p>Pulmonary first pass filtration of particles marginally exceeding ∼7 µm (the size of a red blood cell) is used routinely in diagnostics, and allows cellular aggregates forming or entering the circulation in the preceding cardiac cycle to lodge safely in pulmonary capillaries/arterioles. Pulmonary arteriovenous malformations compromise capillary bed filtration, and are commonly associated with ischaemic stroke. Cohorts with CT-scan evident malformations associated with the highest contrast echocardiographic shunt grades are known to be at higher stroke risk. Our goal was to identify within this broad grouping, which patients were at higher risk of stroke.</p><p>Methodology</p><p>497 consecutive patients with CT-proven pulmonary arteriovenous malformations due to hereditary haemorrhagic telangiectasia were studied. Relationships with radiologically-confirmed clinical ischaemic stroke were examined using logistic regression, receiver operating characteristic analyses, and platelet studies.</p><p>Principal Findings</p><p>Sixty-one individuals (12.3%) had acute, non-iatrogenic ischaemic clinical strokes at a median age of 52 (IQR 41–63) years. In crude and age-adjusted logistic regression, stroke risk was associated not with venous thromboemboli or conventional neurovascular risk factors, but with low serum iron (adjusted odds ratio 0.96 [95% confidence intervals 0.92, 1.00]), and more weakly with low oxygen saturations reflecting a larger right-to-left shunt (adjusted OR 0.96 [0.92, 1.01]). For the same pulmonary arteriovenous malformations, the stroke risk would approximately double with serum iron 6 µmol/L compared to mid-normal range (7–27 µmol/L). Platelet studies confirmed overlooked data that iron deficiency is associated with exuberant platelet aggregation to serotonin (5HT), correcting following iron treatment. By MANOVA, adjusting for participant and 5HT, iron or ferritin explained 14% of the variance in log-transformed aggregation-rate (p = 0.039/p = 0.021).</p><p>Significance</p><p>These data suggest that patients with compromised pulmonary capillary filtration due to pulmonary arteriovenous malformations are at increased risk of ischaemic stroke if they are iron deficient, and that mechanisms are likely to include enhanced aggregation of circulating platelets.</p></div

Monitoring arthropods in a tropical landscape: relative effects of sampling methods and habitat types on trap catches

To discuss the challenge of monitoring multi-species responses of tropical arthropods to disturbance, we considered a large dataset (4 × 105 individuals; 1,682 morphospecies representing 22 focal taxa) based on the work of parataxonomists to examine the effects of anthropogenic disturbance on arthropods at Gamba, Gabon. Replication included three sites in each of four different stages of forest succession and land use after logging, surveyed during a whole year with four sampling methods: pitfall, Malaise, flight-interception and yellow pan traps. We compared the suitability of each sampling method for biological monitoring and evaluated statistically their reliability for 118 arthropod families. Our results suggest that a range of sampling methods yields more diverse material than any single method operated with high replication. Multivariate analyses indicated that morphospecies composition in trap catches was more strongly influenced by habitat type than by sampling methods. This implies that for multi-species monitoring, differences in trap efficiency between habitats may be neglected, as far as habitat types remain well contrasted. We conclude that for the purpose of monitoring large arthropod assemblages in the long-term, a protocol based on operating a set of different and non-disruptive traps appears superior in design than summing a series of taxa-specific protocols

Higher-level bee classifications (Hymenoptera, Apoidea, Apidae sensu lato)

A higher-level classification of bees, in which the entire group is treated as a single family - the Apidae - is advocated here. A total of seven subfamilies, 51 tribes and 27 subtribes are recognized. These subfamilies correspond to the families adopted in the traditional classification. Although the proposed changes do not involve any major rearrangement, basically only changing the rank given to the main groups, the new system makes the classification of bees more consistent with that adopted for other major groups of aculeate Hymenoptera. It also departs from the 19th century practice, perpetuated in the traditional classification, of giving family-status to the main groups of bees. A correspondence table associating the taxon names used in the current traditional classification with those of the revised classification is presented. Scrapterini new tribe (type-genus Scrapter Lepeletier & Serville) is proposed to accommodate the southern African genus Scrapter.<br>Apresenta-se uma classificação para as abelhas em que o todo o grupo é tratado como uma única família - Apidae. São reconhecidas sete subfamílias, 51 tribos e 27 subtribos. As subfamílias correspondem às famílias da classificação tradicional. Apesar das mudanças propostas afetarem apenas o status dos grupos, o novo sistema torna a classificação das abelhas mais consistente com aquela adotada para os grandes grupos de Hymenoptera aculeados. Além disso, distancia-se da tradição de dar status de família aos grupos principais de abelhas, uma prática do século 19 perpetuada na classificação tradicional. É apresentada uma tabela de correspondência associando os nomes dos táxons usados na classificação tradicional corrente com aquelas da classificação sendo proposta aqui. Scrapterini tribo nova (gênero-tipo Scrapter Lepeletier & Serville) é proposta para acomodar Scrapter, um gênero restrito à porção sul do continente africano