Anemia is a significant public health issue that affects a great number of people in developed and developing countries. The World Health Organization states when the Hb value is/dL in an adult male and/dL in a nonpregnant female, the individual is considered as anemic. Iron deficiency is one of the most common causes of anemia. Inadequate intake of iron, chronic blood loss, and/or a combination of both factors typically lead to iron deficiency anemia. In developed countries, chronic blood loss from gastrointestinal, genitourinary, and gynecological sources are the most common etiologies of iron deficiency anemia. Although there are reports of iron deficiency anemia leading to self-inflicted skin excoriation, there are few cases of chronic blood loss from skin excoriation resulting in severe iron deficiency anemia. We present a 49 year old female with significant past medical history of depression, anxiety and chronic back pain who presented after she was found to have profound anemia with hemoglobin of 4.1g/dl. During interviewing, she denied hematuria, hemoptysis, hematochezia, and had been without menstrual cycles for the past year. Urinalysis was negative for blood as well as two documented negative fecal occult blood tests. Iron studies completed showed severely reduced iron levels. Upon further interviewing, the patient reported a supposedly self-diagnosed keratin disorder. For the past ten years she has been self-treating the keratin disorder by applying topical tretinoin and then wrapping it in saran wrap. She would then peel off areas of skin over multiple areas of her body including all extremities and her face. Multiple pictures of bloody piles of tissue were shown. The patient required 3 units of packed red blood cells and was started on iron supplementation. Gastroenterology was consulted and agreed there was no GI source of her blood loss. Psychiatry further evaluated the patient and diagnosed her with obsessive-compulsive disorder with somatic delusions. The prevalence of anemia among chronic psychiatric patients is more frequent than general population. This coexistence deteriorates the quality of life of the patients, prolongs the psychiatric treatment period, and could even cause an increase in morbidity and mortality. Treatment-related factors, drugs taken, physical conditions, negative lifestyle habits, and nutritional disorders are the reasons for anemia among chronic psychiatric patients. Even though iron deficiency anemia in developed country is most often caused by chronic blood loss from gastrointestinal, genitourinary, and gynecological causes, it is important to evaluate for other factors when none of these are present. Psychiatric causes when warranted from history including somatic delusions from obsessive-compulsive disorder should be considered on the differential when other etiologies are less clear.

Neurofibromatosis type 1 is an autosomal dominant neurocutaneous disorder characterized by a mutation of the neurofibromin 1 (NF1) gene, resulting in increased susceptibility for multiple tumors, namely, gastrointestinal stromal tumors (GISTs)-the most common types of mesenchymal neoplasms in the gastrointestinal tract. Despite these tumors' predilection for the stomach, it seems to be the least likely part of the gastrointestinal (GI) tract to be affected in cases of neurofibromatosis. Herein, we report a case of a 61-year-old male patient with known neurofibromatosis, who presented with acute blood loss anemia due to a recurrent gastric GIST, requiring partial gastrectomy due to its size and multiple recurrences.

Iron deficiency anemia is the most common nutritional deficiency disease worldwide (Mahan & Escott-Stump, 2004). Iron deficiency anemia is of major concern especially in women of child bearing age and those who follow a vegetarian diet. The objective of this study was to compare the nutrient and hematological values related to iron status in female university students following a vegetarian versus following a nonvegetarian diet. This study took a cross sectional analysis of 39 female students at California Polytechnic State University (Cal Poly State University) in San Luis Obispo, CA. Of the participants 19 were following a vegetarian diet and 20 were following a nonvegetarian diet. To participate, individuals had to be female, current Cal Poly students, and between the ages of 18 and 22 years old. Those taking vitamin or mineral supplements, medications (including oral contraceptives), smokers, and pregnant women were excluded. Characteristic, demographic, and anthropometric data were collected through interview, nutrient intake was accessed by averaging three day food records, and hematological parameters were measured. Statistical analysis used nonparametric techniques including the Mann-Whitney Wilcoxon statistical test for demographics and baseline characteristics, the Spearman Rank Correlation analysis and Fisher’s Exact statistical test for associations between vegetarians and nonvegetarians. Results found no significant difference in iron intake between vegetarians and nonvegetarians, however nonvegetarians had higher mean intakes of iron at 16.82 (SD 6.36) mg/day compared to vegetarians at 14.84 (SD 7.10) mg/day (p=0.482). A similar percentage of vegetarians at 66.7% (n=8) compared to nonvegetarians at 65% (n=13) were under the Recommended Daily Allowance (18 mg per day for females 19 to 30 years of age) for mean iron consumption. There were slightly more nonvegetarians at 10% (n=2) compared to vegetarians at 8.3% (n=1) under the Estimated Average Requirement (8.1 mg/day for females 19 to 30 years of age) for mean iron intake. No significant difference was found for serum iron, serum ferritin, transferrin saturation, and total iron binding capacity between vegetarians and nonvegetarians. Finding revealed serum ferritin, the most common iron status indicator, was lower for vegetarians at 23.16 (SD15.54) ng/mL compared to nonvegetarians at 27.75 (SD 18.01) ng/mL (p=0.47). When looking at the stages of iron balance, there was greater percentage of vegetarians with hematological results (serum iron <40 µg/dL, total iron binging capacity of >410 µg/dL, transferrin saturation <15%, and serum ferritin <10 ng/mL) indicating iron deficiency anemia or stage IV negative iron balance compared to nonvegetarians. There was no significant correlation between iron intake and serum ferritin, however results showed a positive association (r=0.28, p=0.09). In conclusion, vegetarian participants are believed to be at higher risk of developing negative iron balance compared to nonvegetarians due to lower iron consumption and lower serum ferritin concentrations. Female university students following a vegetarian diet should be educated on iron deficiency anemia and prevention of iron depletion.

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A deficiência de ferro e anemia ferropriva são problemas de ordem mundial. Para as mulheres no período gestacional, a preocupação com o estado do ferro no organismo deve ser ainda maior, pois a deficiência desse elemento pode causar prejuízo na formação dos bebês. O objetivo do projeto é avaliar a evolução da freqüência de deficiência de ferro e anemia ferropriva e os parâmetros de ferro no organismo de mulheres grávidas durante toda a gestação e relacionar com dados da dieta e suplementação de ferro. Também avaliamos os dados sócio-demográficos e nutricionais maternos, além dos parâmetros de ferro, com o peso dos seus recém nascidos. Participaram do estudo 183 gestantes, 103 terminaram o protocolo e das quais foram colhidas amostras de sangue nas idades gestacionais de 16, 28 e 36 semanas. Para avaliação nutricional foram aplicados três inquéritos recordatórios de 24 horas no dia da coleta. Foram realizadas as determinações de ferro sérico, saturação de transferrina, ferritina sérica, capacidade total de ligação ao ferro (CTLF) e concentração sérica do receptor de transferrina (sTfR), além da dosagem da concentração de hemoglobina. As gestantes foram classificadas em seis grupos conforme a suplementação com ferro em cada idade gestacional: as mulheres que não utilizaram essa suplementação foram incluídas no grupo 1 (N=21); enquanto as participantes que fizeram o uso de suplementação em todas as idades gestacionais, até 16 semanas de gravidez e com 28 e 36 semanas de gestação foram incluídas nos grupos 2 (N= 17), 3 (N=12) e 4 (N=24), respectivamente. Os outros 2 grupos foram constituídos por mulheres que utilizaram a suplementação somente com 28 semanas de gestação (Grupo 5, N= 19) e com 36 semanas de gestação (grupo 6 , N= 10). Não houve correlação entre os consumo de ferro da dieta e os parâmetros que avaliam o estado do ferro no sangue. Houve aumento da freqüência de deficiência de ferro em todos os grupos estudados, mas não ocorreu aumento da freqüência de anemia e nem anemia ferropriva. / Iron deficiency and iron deficiency anemia are worldwilde problems. For women during pregnancy, concern about the iron status should be even higher, because the iron deficiency may impair the formation of newborn. The objectives of this work was evaluate the frequency of iron deficiency and iron deficiency anemia and iron status markers of pregnant women during pregnancy and correlate with diet intake and iron supplementation. We also assess the socio-demographic, maternal nutrition and iron status with birth weight of their newborns. The study included 183 women, 103 completed the protocol. Blood samples was collected at gestational ages of 16, 28 and 36 weeks. Nutrient intake was assessed by 24 hour dietary recall applied at the same time of blood samples. We analyzed serum iron, transferrin saturation, serum ferritin, total iron binding capacity (TIBC), serum transferrin receptor (sTfR), and hemoglobin. Patients were classified into six groups according to iron supplementation: women who did not use this supplement were included in group 1 (N = 21), while the participants who made use of supplementation in all gestational ages, up to 16 weeks of gestation, in 28 and 36 weeks of gestation were included in group 2 (N = 17), 3 (N = 12) and 4 (N = 24), respectively. The other 2 groups consisted of women who used supplement in 28 weeks of gestation (Group 5, N = 19) and 36 weeks of gestation (group 6, N = 10). There was no correlationship between diet intake of iron and iron status markers. The frequencies of iron deficiency increased during pregnancy in all groups , however the frequencies of anemia and iron deficiency anemia did not.

We estimated the prevalence of iron deficiency anemia (IDA) in women 1-year postpartum in central Montreal. Blood samples were obtained by venipuncture and questionnaires administered. Iron intake was assessed by a food frequency questionnaire. Mothers with at least two of the following laboratory values were considered to have IDA: serum ferritin (SF) < 12 mug/L, mean corpuscular volume (MCV) < 80 fL and hemoglobin (Hb) < 120 g/L. Blood samples were analysed for 201 women. The estimates of prevalence of anemia (Hb < 120 g/L), iron deficiency (SF < 12 mug/L) and IDA were 7.0% (95% confidence interval [CI] 3.8%-10.9%), 5.5% (95% CI 2.5%-8.9%) and 2.5% (95% CI 0.3%-4.7%) respectively. No significant differences were observed between level of income and anemia, iron deficiency and IDA rates. Anemia was not related to dietary iron intake. In conclusion, the prevalence of IDA is low among healthy women 1-year postpartum in central Montreal.

Background: The Zanzibar Infant Nutrition Campaign is a large-scale randomised control trial investigating the effects of iron and zinc supplementation on the morbidity and mortality of infants and young children on Pemba Island, Zanzibar, Tanzania. The Child Development Study is a substudy of the larger ZINC control trial assessing the effects of 12 months of iron and zinc supplementation on motor and language development. The Caregiver-Infant Interaction Study is a substudy of the Child Development Study, assessing the effects of 1 to 3 months of iron and zinc supplementation on caregiver-infant interaction among 9-month-old dyads. This thesis reports on the dyads enrolled in the Caregiver-Infant Interaction Study. While not examining treatment effects1 • Formulate behavioural and developmental hypotheses specific to a population of 9-month-old caregiver-infant dyads affected by a history of IDA , hypothesised disturbances in the behaviour and development of infants affected by a history of iron deficiency anaemia (IDA) are examined. Objectives: • Develop a hypothesis-driven observational coding system and establish the psychometric properties of this measure • Test hypotheses about the relationship between a history of IDA and the behaviour and development of 9-month-old caregiver-infant dyads Rationale: Iron deficiency anaemia is the most common nutritional disorder in the world. Prevalence is especially high among women, young children and infants in developing countries. As a public health concern, the effects of IDA are various and insidious, however the relationship between IDA and infant behaviour and development is not known. The majority of studies concerned with the impact of IDA in infancy have relied on global developmental scales, such as the Bayley Scales of Infant Development (Bayley, 1969, 1993). While infants with IDA consistently score worse than non-anaemic comparisons on mental and motor subscales, the value of this form of assessment is known to be limited. Apart from being of questionable validity as indices of abilities or functions (e.g., Fagan & Singer, 1983), the scores and ratings produced by traditional developmental scales are not designed to assess the specific functions hypothesised to be affected by IDA (Lozoff, De Andraca, Castillo, Smith, Walter & Pino, 2003). Over-reliance on this kind of measure thus rules out meaningful hypothesis-driven research. Recently, malnutrition researchers have begun to made use of systematic behavioural observation as a means of assessment. While a promising approach, extant research is limited to only two studies (see Footnote 6), and both of these have been conducted by the same research group. Moreover, these studies have relied on fairly rudimentary behavioural coding to examine a version of the ‘Functional Isolation Hypothesis', originally proposed some time ago in the infrahuman literature (Levitsky & Barns, 1972, 1973). More sophisticated hypotheses are available, especially given the ready availability of insights from developmental psychobiology and cognitive science. Design: A correlational design was used to examine the behaviour and development of 9-month old caregiver-infant dyads with a history of IDA. Setting: Wete District, Pemba Island, Zanzibar, Tanzania. Participants: 160 Caregiver-infant dyads assessed observationally at 9-month of age. Main Outcome Measure: Systematic observational coding. Main Findings: Infants with a history of more severe IDA spent significantly less time in high energy states during free play, and their caregivers made less physically demanding requests. A history of IDA also correlated with developmental disturbances in postural control. Affectively, IDA infants were hypo-responsive, and caregivers showed more (overt) positive affect for healthy males, but not females. Caregivers coordinated actions and vocalizations less often during interaction with infants affected by a history of IDA. Conclusion: A history of IDA among 9-month old infants is related to behavioural and developmental disturbances in both motor and socio-cognitive domains. Note to reader: The present research was first submitted as a Masters dissertation in 2008. The author was subsequently offered the opportunity rather to upgrade to a Doctoral thesis and resubmit the work as PhD. Chronologically then, studies which did not inform the design and development of the coding system used for data collection, or which published findings after the first submission of the present work, are discussed in the final chapter. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2009.

To assess the prevalence of anemia, we surveyed 10 to 14 month old infants of families with heterogeneous socio-economic backgrounds from four regions of inner-city Montreal. Capillary blood was drawn to measure hemoglobin (Hb), mean corpuscular volume (MCV), and serum ferritin (SF). A home-visit questionnaire assessed infant feeding practices and potential confounding variables. In the overall sample, the prevalence was 14.3% for anemia (Hb≥110 g/L), 9.4% for iron deficiency (SF≤10 mug/L), and 4.3% for iron deficiency anemia (SF≤10 mug/L and Hb≤110 g/L or MCV≤72 fL). There were no significant differences in iron status indices between socio-economic subgroups. Protectors of anemia determined through logistic regression analysis were introduction of cow's milk at or following 9 months of age (OR 0.17 [95% CI 0.056 to 0.540]) and breastfeeding for 6 months or less (OR 0.23 [95% CI 0.086 to 0.637]). Our results suggest that important health inequalities relating to anemia do not currently exist among infants residing in Montreal.

Orientador: Helena Zerlotti Wolf Grotto / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-14T08:24:50Z (GMT). No. of bitstreams: 1 Alvarenga_ElianadaCosta.pdf: 3519502 bytes, checksum: cc024f9bd1176e4c4f56d989bba5a487 (MD5) Previous issue date: 2009 / Resumo: A deficiência de ferro é provavelmente o distúrbio nutricional mais freqüente no mundo. O ferro é um componente essencial da molécula de hemoglobina, da mioglobina e de diversas enzimas. Tem papel fundamental no transporte de oxigênio, na transferência de elétrons e atua como cofator em muitos processos enzimáticos, incluindo a síntese de DNA. Diversos estudos têm mostrado a contribuição da infecção pelo Helicobacter pylori (H. pylori) no desenvolvimento da anemia ferropriva e a associação entre o H. pylori e a diminuição do estoque de ferro. O objetivo do presente trabalho foi verificar a possível associação entre a infecção pelo H. pylori e a deficiência de ferro em um grupo de pacientes adultos. Desse modo pretendeu-se conhecer melhor as alterações hematológicas presentes nos pacientes infectados pelo H. pylori, principalmente as relacionadas ao metabolismo do ferro. Foram estudados 156 pacientes adultos de ambos os sexos que foram submetidos à endoscopia digestiva alta para esclarecimento diagnóstico. Desses 156 pacientes, 125 apresentaram alterações à endoscopia, que justificaram a realização da biópsia gástrica. A avaliação da presença de anemia foi feita pelos dados hematimétricos e pelo conteúdo de hemoglobina dos reticulócitos (Ret-He) e o estado do ferro foi avaliado pelas dosagens de ferro sérico, capacidade de ligação do ferro à transferrina e ferritina sérica. A possível participação da atividade inflamatória na eritropoiese foi verificada pela correlação entre os parâmetros hematimétricos e do estado do ferro com os níveis de proteína C reativa (PC-R). O diagnóstico do H. pylori foi realizado através da análise histológica, teste da urease e teste sorológico (IgG anti- H. pylori). Os 125 pacientes foram separados em H. pylori positivo (n= 75) e negativo (n= 50). Não houve diferença significativa nos valores dos parâmetros hematológicos e bioquímicos, tendo sido diferentes somente os valores de IgG anti-H. pylori e de gastrina sérica, significativamente superiores no grupo H. pylori positivo. Foi observada uma correlação inversa fraca, mas significativa entre os níveis de PC-R e Ret-He e entre gastrina sérica e Ret-He no grupo H. pylori positivo. De acordo com os critérios laboratoriais, dos 125 pacientes apenas 17 (13,6%) mostraram níveis de Hb indicativos de anemia, sendo que desses, 7 (5,6%) mostraram ser positivos para a infecção pelo H. pylori. Não foi observada diferença na freqüência da deficiência de ferro entre os grupos de pacientes infectados pelo H. pylori e os não infectados pelo H. pylori. Dentre os pacientes estudados a gastrite foi confirmada em 110 pacientes, sendo que 74 (67,2%) eram H. pylori positivo. A gastrite foi classificada de acordo com o sistema de Sidney em: moderada/intensa (36.63%), leve (63,37%) e inespecífica (8,1%). Quando os pacientes com gastrite moderada/intensa foram comparados com os com gastrite leve, não houve diferença entre os parâmetros estudados, exceto os valores da titulação de IgG, que foram significativamente superiores no grupo com gastrite moderada/intensa. Portanto, podemos concluir que no grupo de indivíduos estudados a infecção pelo H. pylori e a intensidade da gastrite não foram fatores determinantes ao desenvolvimento da deficiência de ferro. / Abstract: Iron deficiency is probably the most common nutritional disorder in the world. Iron is an essential component of the molecule of hemoglobin, myoglobin and various enzymes. It has a fundamental role in oxygen transport, in electrons transference and acts as a cofactor in many enzymatic processes, including synthesis of DNA. Several studies have shown the contribution of Helicobacter pylori (H. pylori) infection in the development of anemia and the association between H. pylori and reduction of iron store. The objective of this study was to investigate the association between H. pylori infection and iron deficiency in a group of adult patients. Thus we intend to study the hematological alterations in H. pylori infected patients, mainly those related to iron metabolism. We studied 156 adult patients of both sex undergoing routine upper endoscopy. Of these 156 patients, 125 had gastric biopsies stained for H. pylori identification. The evaluation of the presence of anemia was performed by erythrocyte indeces and reticulocyte hemoglobin content (RET-He) and the iron status was assessed by measurements of serum iron, iron binding capacity of the transferrin and serum ferritin levels. Inflammatory activity influence on erythropoiesis was verified by the correlation among erythrocyte parameters and the state of the iron with C-reactive protein (CR-P) levels. The diagnosis of H. pylori was performed by histological, urease and serological (IgG anti-H. pylori) methods. Patients were divided into H. pylori positive (n = 75) and negative (n = 50). There was no significant difference in hematological and biochemical parameters, except for IgG anti-H. pylori values and serum gastrin, significantly higher in H. pylori positive group. There was a weak but significant inverse correlation between CR-P and Ret-He levels and between serum gastrin and Ret-He in H. pylori positive group. According to laboratory criteria, only 17 of 125 patients (13.6%) showed levels of hemoglobin indicative of anemia, 7 of 17 patients were positive for H. pylori infection. There was no difference in the frequency of iron deficiency anemia between H. pylori positive and negative groups. Gastritis was confirmed in 110 patients, of these 74 (67.2%) were H. pylori positive. The gastritis was classified according to the Sydney system as: moderate / severe (36.63%), mild (63.37%) and nonspecific (8.1%). There was no difference between groups with moderate/ severe gastritis and mild gastritis concerning hematologic and biochemical parameters, except the values of the titers of IgG, which were significantly higher in the group with moderate / severe gastritis. Therefore, we conclude that infection by H. pylori and the intensity of gastritis were not determining factors for the development of iron deficiency in the studied group. / Universidade Estadual de Campi / Ciencias Biomedicas / Mestre em Ciências Médicas