Iron-deficiency anemia and hematochezia: when is colonoscopy appropriate?

Background: Colonoscopy is usually proposed for the evaluation of lower gastrointestinal blood loss (hematochezia) or iron deficiency anemia (IDA). Clinical practice guidelines support this approach but formal evidence is lacking. Real clinical scenarios made available on the web would be of great help in decision-making in clinical practice as to whether colonoscopy is appropriate for a given patient. Method: A multidisciplinary multinational expert panel (EPAGE II) developed appropriateness criteria based on best published evidence (systematic reviews, clinical trials, guidelines) and experts' judgement. Using the explicit RAND Appropriateness Method (3 round of experts' votes and a panel meeting) 102 clinical scenarios were judged inappropriate, uncertain, appropriate, or necessary. Results: In IDA, colonoscopy was appropriate in patients >50 years and necessary in the presence of lower abdominal symptoms. In both men and women aged <50 years, colonoscopy was appropriate if prior sigmoidoscopy and/or gastroscopy did not explain the IDA, and necessary if lower gastrointestinal symptoms were present. In women <50 years with a potential gynecological cause, additional lower gastrointestinal symptoms rendered colonoscopy appropriate. In patients >50 years with hematochezia, colonoscopy was always appropriate and mostly necessary, except if a prior colonoscopy was normal within the previous 5 years. Under age 50 years, the presence of any risk factor for colorectal cancer (CRC) and no previous normal colonoscopy (within the last 5 years) made this procedure appropriate and necessary. Conclusion: Colonoscopy is appropriate and even necessary for many indications related to iron deficiency anemia or hematochezia, in particular in patients aged >50 years. The main factors influencing appropriateness are age, results of prior investigations (sigmoidoscopy, gastroscopy, previous colonoscopy), CRC risk and sex. EPAGE II appropriateness criteria are available on www.epage.ch

Petrology, geochemistry and geodynamic implications of Jurassic island arc magmatism as revealed by mafic volcanic rocks in the Mesozoic low-grade sequence, eastern Rhodope, Bulgaria

In the eastern Bulgarian Rhodope, mafic extrusive rocks and underlying greenschists are found in the Mesozoic low-grade unit, which represents the northern extension of similar sequences including the Evros ophiolites in Thrace (Greece). Both rock types define a suite of low-Ti tholeiitic basalts to transitional boninitic basaltic andesites and andesites and associated metapyroclastites (greenschists), intruded at its base by diorite dikes of a boninitic affinity. Mafic lavas and greenschists display large ion lithophile element (LILE) enrichment relative to high-field strength elements (HFSE), flat REE patterns of a slight light REE depletion, a strong island arc tholeiite (IAT) and weak MORB-like signature. All these rocks are characterized by negative Nb anomalies ascribed to arc lavas. They have positive epsilon Nd(i) values in the range of +4.87 to +6.09, approaching the lower limit of MORB-like source, and relatively high ((207)Pb/(204)Pb)(i) (15.57-15.663) at low ((206)Pb/(204)Pb)(i) (18.13-18.54) ratios. The Nd isotopic compositions coupled with trace element data imply a dominantly depleted MORB-like mantle source and a contribution of subduction modified LILE-enriched component derived from the mantle wedge. The diorite dike has a low eNdi value of -2.61 and is slightly more Pb radiogenic ((207)Pb/(204)Pb)(i) (15.64) and ((206)Pb/(204)Pb)(i) (18.56), respectively, reflecting crustal contamination. Petrologic and geochemical data indicate that the greenschists and mafic extrusive rocks represent a magmatic assemblage formed in an island arc setting. The magmatic suite is interpreted as representing an island arc-accretionary complex related to the southward subduction of the Meliata-Maliac ocean under the supra-subduction back-arc Vardar ocean/island arc system. Magmatic activity appears to have initiated in the north during the inception of the island arc system by the Early-Middle Jurassic time in the eastern Rhodope that most likely graded to back-arc spreading southwards as represented by the Late Jurassic MORB-type Samothraki Island ophiolites. This tectonic scenario is further constrained by paleotectonic reconstructions. The arc-trench system collided with the Rhodope in the Late Jurassic times. (c) 2007 Elsevier B.V. All rights reserved.

La actividad productiva de la fábrica de harinas “La Montserrat” (Girona) en el año agrícola de 1903-1904 = The Production Activities at the Company Harinera “La Montserrat” (Girona) over the Agricultural Year 1903-1904

Harinera La Montserrat, S.A, a company involved in the manufacturing and trading of cereals and flour, was founded in Girona in 1898 by José Ensesa y Cía., Sociedad en Comandita. With the objective to determine how the product activity of this business was structured, we have studied in detail the operations that were carried out over the agricultural year 1903-1904. We have focused on three main aspects. Firstly, the purchasing of wheat (origin, transportation, prices); secondly, the production of flour (using internal and external wheat, profits); and thirdly, its distribution (customers, destination). Finally, we have analyzed the profit and loos account for this period in order to find out if this business was profitable

How Wages and Employment Adjust to Trade Liberalization: Quasi-Experimental Evidence from Austria

We study the response of regional employment and nominal wages to trade liberalization, exploiting the natural experiment provided by the opening of Central and Eastern European markets after the fall of the Iron Curtain in 1990. Using data for Austrian municipalities, we examine di¤erential pre- and post-1990 wage and employment growth rates between regions bordering the formerly communist economies and interior regions. If the 'border regions'are de...ned narrowly, within a band of less than 50 kilometers, we can identify statistically signi...cant liberalization e¤ects on both employment and wages. While wages responded earlier than employment, the employment e¤ect over the entire adjustment period is estimated to be around three times as large as the wage e¤ect. The implied slope of the regional labor supply curve can be replicated in an economic geography model that features obstacles to labor migration due to immobile housing and to heterogeneous locational preferences.

Learning form Nature to improve the heat generation of iron-oxide nanoparticles for magnetic hyperthermia applications.

The performance of magnetic nanoparticles is intimately entwined with their structure, mean size and magnetic anisotropy. Besides, ensembles offer a unique way of engineering the magnetic response by modifying the strength of the dipolar interactions between particles. Here we report on an experimental and theoretical analysis of magnetic hyperthermia, a rapidly developing technique in medical research and oncology. Experimentally, we demonstrate that single-domain cubic iron oxide particles resembling bacterial magnetosomes have superior magnetic heating efficiency compared to spherical particles of similar sizes. Monte Carlo simulations at the atomic level corroborate the larger anisotropy of the cubic particles in comparison with the spherical ones, thus evidencing the beneficial role of surface anisotropy in the improved heating power. Moreover we establish a quantitative link between the particle assembling, the interactions and the heating properties. This knowledge opens new perspectives for improved hyperthermia, an alternative to conventional cancer therapies.

Appropriateness of colonoscopy in Europe (EPAGE II). Iron-deficiency anemia and hematochezia.

BACKGROUND AND STUDY AIMS: To summarize the published literature on assessment of appropriateness of colonoscopy for the investigation of iron-deficiency anemia (IDA) and hematochezia, and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. METHODS: A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of IDA and hematochezia was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. RESULTS: IDA occurs in 2 %-5 % of adult men and postmenopausal women. Examination of both the upper and lower gastrointestinal tract is recommended in patients with iron deficiency. Colonoscopy for IDA yields one colorectal cancer (CRC) in every 9-13 colonoscopies. Hematochezia is a well-recognized alarm symptom and such patients are likely to be referred for colonoscopy. Colonoscopy is unanimously recommended in patients aged > or = 50. Diverticulosis, vascular ectasias, and ischemic colitis are common causes of acute lower gastrointestinal bleeding (LGIB); CRC is found in 0.2 %-11 % of the colonoscopies performed for LGIB. Most patients with scant hematochezia have an anorectal or a distal source of bleeding. The expert panel considered most clinical indications for colonoscopy as appropriate in the presence of IDA (58 %) or hematochezia (83 %). CONCLUSION: Despite the limitations of the published studies, guidelines unanimously recommend colonoscopy for the investigation of IDA and hematochezia in patients aged > or = 50 years. These indications were also considered appropriate by EPAGE II, as were indications in patients at low risk for CRC with no obvious cause of bleeding found during adequate previous investigations.

Marqueurs diagnostiques de la carence en fer: lequel choisir [Diagnostic markers of iron deficiency: which should we choose?].

Iron deficiency is generally investigated when faced with anemia, or with symptoms that could be related to iron deficiency without anemia. This simple disorder is easy to treat, provided that the diagnosis is correct. Several biological tests are available, but their interpretation is oftentimes problematic. Pre-analytical factors can interfere with measurements, normal values can change depending on suppliers, and, above all, results from different markers can be contradictory in some clinical situations. The aim of this article is to evaluate how the evolution of scientific knowledge and clinical trials can contribute to a better understanding and greater reliability in the diagnosis of iron deficiency.

Hibernia: An Irish Immigrant Neighborhood in Burlington, Iowa, 2000

Hibernia is mostly a memory today as is so many immigrant neighborhoods. However, there are several guideposts to the past that still witness to the history of years gone by, such as St. Patrick's Church, a beacon reflecting the Irish Catholic heritage. Murray Iron Works and the Embalming Burial Case Company and the worker's homes on the surrounding streets witness to the industrial/employee relationship of the past.

A case study of landslides and coping strategies in two villages of central-eastern Nepal

Landslides are an increasing problem in Nepal's Middle Hills due to both natural and human phenomena: mainly increasingly intense monsoon rains and a boom in rural road construction. This problem has largely been neglected due to underreporting of losses and the dispersed nature of landslides. Understanding how populations cope with landslides is a first step toward developing more effective landslide risk management programs. The present research focuses on two villages in Central-Eastern Nepal, both affected by active landslides but with different coping strategies. Research methods are interdisciplinary, based on a geological assessment of landslide risk and a socio-economic study of the villages using household questionnaires, focus group discussions and transect walks. Community risk maps are compared with geological landslide risk maps to better understand and communicate community risk perceptions, priorities and coping strategies. A modified typology of coping strategies is presented, based on previous work by Burton, Kates, and White (1993) that is useful for decision-makers for designing more effective programs for landslide mitigation. Main findings underscore that coping strategies, mainly seeking external assistance and outmigration, are closely linked to access to resources, ethnicity/social status and levels of community organization. Conclusions include the importance of investing in organizational skills, while building on local knowledge about landslide mitigation for reducing landslide risk. There is great potential to increase coping strategies by incorporating skills training on landslide mitigation in existing agricultural outreach and community forest user group training.

Iowa Historic Property Study: Iowana Farms Milk Company, 1416 State Street, City of Bettendorf, Scott County, Iowa, 2012

The Iowana Farms Milk Company factory building was considered to retain sufficient integrity and possess sufficient significance to be considered eligible for the National Register of Historic Places under Criteria A and C for its historical and architectural significance in the Bettendorf community. The Iowana Farms Milk Company was an important early to mid-twentieth-century business in Bettendorf, and was among the few that was not owned or operated by the Bettendorf Company. It was a strong and thriving business for many years, and its products were well known in the Quad Cities region. The importance of this property becomes even more significant when one considers that most of the buildings once associated with the actual Bettendorf Company, which was undeniably the most important business and industry in town, are now gone. As a result, the Iowana Farms Milk Company factory building was a physical vestige of the once-thriving commercial industries that made Bettendorf into a city in the twentieth century. This property was further significant for its representation of the evolution of the dairy industry in the twentieth century from farm to factory production. It also reflected the changes to the industry based on scientific discoveries, mechanical innovations, and governmental regulations related to improved sanitation and the pure milk movement. The Iowana Farms Milk Company represented a model plant for the time, and the marketing strategies it employed followed the trends of the industry. The Iowana Farms Milk Company plant had to be removed to make room for a new I-74 bridge over the Mississippi River at Bettendorf. The construction of the new bridge also required removal of the historic Iowa-Illinois Memorial Bridge. The documentation reported herein and for that of the Iowa-Illinois Memorial Bridge fulfills the requirements of the Memorandum of Agreement regarding the removal of these historic properties.

Human inhalation exposure to iron oxide particles

In the past decade, many studies have been conducted to determine the health effects induced by exposure to engineered nanomaterials (NMs). Specifically for exposure via inhalation, numerous in vitro and animal in vivo inhalation toxicity studies on several types of NMs have been published. However, these results are not easily extrapolated to judge the effects of inhaling NMs in humans, and few published studies on the human response to inhalation of NMs exist. Given the emergence of more industries utilizing iron oxide nanoparticles as well as more nanomedicine applications of superparamagnetic iron oxide nanoparticles (SPIONs), this review presents an overview of the inhalation studies that have been conducted in humans on iron oxides. Both occupational exposure studies on complex iron oxide dusts and fumes, as well as human clinical studies on aerosolized, micron-size iron oxide particles are discussed. Iron oxide particles have not been described to elicit acute inhalation response nor promote lung disease after chronic exposure. The few human clinical studies comparing inhalation of fine and ultrafine metal oxide particles report no acute changes in the health parameters measured. Taken together existing evidence suggests that controlled human exposure to iron oxide nanoparticles, such as SPIONs, could be conducted safely.

Iron mining in Goa (India) : an interdisciplinary study

En aquest article es presenten breument els diferents capítols d’un treball interdisciplinari per tal d’entendre el context de prohibició de la mineria de ferro a Goa a finals del 2012 i proporcionar la informació necessària per tal d’orientar i gestionar la presa de decisions sobre l’activitat minera en un futur. Els sis primers capítols consisteixen en l’estudi del medi abiòtic, medi biòtic, fluxos de materials, aspectes socials, aspectes econòmics i finalment aspectes polítics. En canvi, en els dos últims capítols s'avaluen i es gestionen els impactes ambientals de la mineria mitjançant, per una banda, una anàlisi DPSIR i, d'altra banda, es proposen tres escenaris per integrar les diferents variables i fomentar la participació en la presa de decisions. S’ha dut a terme una extensa recerca mitjançant la recopilació de dades, entrevistes i visites a les zones d’estudi d’interès per tal d’entendre el conflicte de la mineria a Goa.

Severe and prolonged hypophosphatemia after intravenous iron administration in a malnourished patient.

Malnutrition may result in a phosphate-deficient state owing to a chronically insufficient phosphate intake. Concomitant iron deficiency is common and often supplemented by the intravenous route. It is not widely recognized that some parenteral iron formulations can induce hypophosphatemia. Herein we report a case of a severe and symptomatic hypophosphatemia (0.18 mM, normal range 0.8-1.4 mM) associated with an inappropriately reduced tubular reabsorption of phosphate (33%, norm >95%) in a malnourished patient with anorexia/bulimia who received 2 × 500 mg iron carboxymaltose (FCM) intravenously. Despite intravenous and oral phosphate supplements, it required 2 months to achieve a normal serum phosphate level. Our case demonstrates that in a chronically malnourished and phosphate-deficient state intravenous FCM could potentially be dangerous. If this form of iron application cannot be avoided, phosphate supplementation before and after iron infusion as well as close monitoring of phosphate levels are needed.

Empirical errors of small area estimates from the multisource National Forest Inventory in Eastern Finland

Abstract

Rhizosphere properties of rice genotypes as influenced by anoxia and availability of zinc and iron

The objective of this work was to study possible mechanisms involved in root-induced changes of rhizosphere physicochemical properties of rice genotypes, under anoxia and low supply of Zn and Fe. Two rice genotypes, including an upland and a lowland ones, were grown in hydroponic medium under adequate and low supply of Zn and Fe, with or without aeration. Anoxia increased shoot dry weight, root length and uptake of Zn and Fe in lowland Amol genotype, but reduced these parameters in upland Gasrol-Dashti genotype. The amount of oxygen released by roots was statistically higher in 'Amol'. The highest acidification potential of roots was observed in the lowland genotype under low supply of Zn, and in the upland genotype under Fe starvation. The highest oxalate (only organic acid detected) exudation from roots was observed in Zn and Fe deficient Gasrol-Dashti genotype. Zinc deficiency caused reduction of alcohol dehydrogenase and stimulation of lactate dehydrogenase activity, particularly in shoot. The ability to induce changes in the rhizosphere properties has a great contribution for the adaptation of both lowland and upland rice genotypes to specific soil conditions.