The incidence, complications, and treatment of iron deficiency in pregnancy.

Iron deficiency and/or iron deficiency anemia (IDA) complicate nearly 50% of pregnancies globally, negatively impacting both maternal and fetal outcomes. Iron deficiency can cause a range of symptoms that range from aggravating to debilitating including fatigue, poor quality of life, pagophagia, and restless leg syndrome. Iron deficiency and IDA are also associated with maternal complications including preterm labor, increased rates of cesarean delivery, postpartum hemorrhage, and maternal death. Fetal complications include increased rates of low birth weight and small for gestational age newborns. Prenatal maternal anemia has also been associated with autism spectrum disorders in the neonate, although causation is not established. Deficiency in the newborn is associated with compromised memory, processing, and bonding, with some of these deficits persisting into adulthood. Despite the prevalence and consequences associated with iron deficiency in pregnancy, data show that it is routinely undertreated. Due to the physiologic changes of pregnancy, all pregnant individuals should receive oral iron supplementation. However, the bioavailability of oral iron is poor and it is often ineffective at preventing and treating iron deficiency. Likewise, it frequently causes gastrointestinal symptoms that can worsen the quality of life in pregnancy. Intravenous iron formulations administered in a single or multiple dose series are now available. There is increasing data suggesting that newer intravenous formulations are safe and effective in the second and third trimesters and should be strongly considered in pregnant individuals without optimal response to oral iron repletion.

An International Collaborative Standardizing a Comprehensive Patient-Centered Outcomes Measurement Set for Colorectal Cancer.

IMPORTANCE: Global health systems are shifting toward value-based care in an effort to drive better outcomes in the setting of rising health care costs. This shift requires a common definition of value, starting with the outcomes that matter most to patients. OBJECTIVE: The International Consortium for Health Outcomes Measurement (ICHOM), a nonprofit initiative, was formed to define standard sets of outcomes by medical condition. In this article, we report the efforts of ICHOM's working group in colorectal cancer. EVIDENCE REVIEW: The working group was composed of multidisciplinary oncology specialists in medicine, surgery, radiation therapy, palliative care, nursing, and pathology, along with patient representatives. Through a modified Delphi process during 8 months (July 8, 2015 to February 29, 2016), ICHOM led the working group to a consensus on a final recommended standard set. The process was supported by a systematic PubMed literature review (1042 randomized clinical trials and guidelines from June 3, 2005, to June 3, 2015), a patient focus group (11 patients with early and metastatic colorectal cancer convened during a teleconference in August 2015), and a patient validation survey (among 276 patients with and survivors of colorectal cancer between October 15, 2015, and November 4, 2015). FINDINGS: After consolidating findings of the literature review and focus group meeting, a list of 40 outcomes was presented to the WG and underwent voting. The final recommendation includes outcomes in the following categories: survival and disease control, disutility of care, degree of health, and quality of death. Selected case-mix factors were recommended to be collected at baseline to facilitate comparison of results across treatments and health care professionals. CONCLUSIONS: A standardized set of patient-centered outcome measures to inform value-based health care in colorectal cancer was developed. Pilot efforts are under way to measure the standard set among members of the working group.

Follow-up care, surveillance protocol, and secondary prevention measures for survivors of colorectal cancer: American Society of Clinical Oncology clinical practice guideline endorsement.

PURPOSE: The American Society of Clinical Oncology (ASCO) has a policy and set of procedures for endorsing recent clinical practice guidelines that have been developed by other professional organizations. METHODS: The Cancer Care Ontario (CCO) Guideline on Follow-up Care, Surveillance Protocol, and Secondary Prevention Measures for Survivors of Colorectal Cancer was reviewed by ASCO for methodologic rigor and considered for endorsement. RESULTS: The ASCO Panel concurred with the CCO recommendations and recommended endorsement, with the addition of several qualifying statements. CONCLUSION: Surveillance should be guided by presumed risk of recurrence and functional status of the patient (important within the first 2 to 4 years). Medical history, physical examination, and carcinoembryonic antigen testing should be performed every 3 to 6 months for 5 years. Patients at higher risk of recurrence should be considered for testing in the more frequent end of the range. A computed tomography scan (abdominal and chest) is recommended annually for 3 years, in most cases. Positron emission tomography scans should not be used for surveillance outside of a clinical trial. A surveillance colonoscopy should be performed 1 year after the initial surgery and then every 5 years, dictated by the findings of the previous one. If a colonoscopy was not preformed before diagnosis, it should be done after completion of adjuvant therapy (before 1 year). Secondary prevention (maintaining a healthy body weight and active lifestyle) is recommended. If a patient is not a candidate for surgery or systemic therapy because of severe comorbid conditions, surveillance tests should not be performed. A treatment plan from the specialist should have clear directions on appropriate follow-up by a nonspecialist.

Retrospective case study of team approach to omphalocele orthosis fabrication and implementation.

PURPOSE: The purpose of this case report is to describe an interdisciplinary approach to orthotic intervention in a neonate with giant omphalocele. SUMMARY OF KEY POINTS: An infant with a giant omphalocele was presented to the Neonatal Intensive Care Unit (NICU) for management. An interdisciplinary team including a neonatal surgeon, physical therapists, orthotist, and family collaborated to determine appropriate orthotic intervention. A custom stabilizing orthosis and prone positioning device were fabricated and fit to the infant. The omphalocele was secure and the family felt confident that the omphalocele was protected during physical interaction. SUMMARY AND RECOMMENDATIONS FOR CLINICAL PRACTICE: In this case, a custom orthosis was shown to be a valuable tool to provide external support for a giant omphalocele and facilitate safe interaction between infant and family. An interdisciplinary approach is recommended to best accommodate the patient's needs.

Implantation-associated changes in bovine uterine expression of integrins and extracellular matrix.

Appropriate integrin expression appears to be necessary for successful implantation of human embryos and varies considerably among species. The present study was undertaken to determine the distributions of integrin subunits alpha(1), alpha(3), and alpha(6) as well as the extracellular matrix (ECM) components collagen IV and laminin in implanting bovine trophoblast and endometrium. Immunohistochemical staining of cryostat sections prepared from nonpregnant endometrium, of preattachment through to early villus development pregnant endometrium (Days 18, 21, 24, and 30), and of isolated trophoblast binucleate cells was performed. Trophoblast down-regulated the integrin alpha(1) subunit as attachment proceeded, whereas reactivity scores for alpha(6) antibody tended to increase from Day 18 through 24 and remained high. A subpopulation of trophoblast binucleate cells expressed the alpha(3) integrin subunit. Uterine epithelium constitutively expressed alpha(3) and alpha(6) integrin subunits, but the alpha(1) subunit was down-regulated as the luminal epithelium was modified. Collagen IV and laminin reactivity increased in the basal lamina and underlying subepithelial stroma as pregnancy proceeded. The results suggest that binucleate cell fusion with the maternal epithelium initiates integrin and ECM changes in the subepithelial stroma.