OPTIMAL: An OPTimized Imaging Mass cytometry AnaLysis framework for benchmarking segmentation and data exploration.

Analysis of imaging mass cytometry (IMC) data and other low-resolution multiplexed tissue imaging technologies is often confounded by poor single-cell segmentation and suboptimal approaches for data visualization and exploration. This can lead to inaccurate identification of cell phenotypes, states, or spatial relationships compared to reference data from single-cell suspension technologies. To this end we have developed the "OPTimized Imaging Mass cytometry AnaLysis (OPTIMAL)" framework to benchmark any approaches for cell segmentation, parameter transformation, batch effect correction, data visualization/clustering, and spatial neighborhood analysis. Using a panel of 27 metal-tagged antibodies recognizing well-characterized phenotypic and functional markers to stain the same Formalin-Fixed Paraffin Embedded (FFPE) human tonsil sample tissue microarray over 12 temporally distinct batches we tested several cell segmentation models, a range of different arcsinh cofactor parameter transformation values, 5 different dimensionality reduction algorithms, and 2 clustering methods. Finally, we assessed the optimal approach for performing neighborhood analysis. We found that single-cell segmentation was improved by the use of an Ilastik-derived probability map but that issues with poor segmentation were only really evident after clustering and cell type/state identification and not always evident when using "classical" bivariate data display techniques. The optimal arcsinh cofactor for parameter transformation was 1 as it maximized the statistical separation between negative and positive signal distributions and a simple Z-score normalization step after arcsinh transformation eliminated batch effects. Of the five different dimensionality reduction approaches tested, PacMap gave the best data structure with FLOWSOM clustering out-performing phenograph in terms of cell type identification. We also found that neighborhood analysis was influenced by the method used for finding neighboring cells with a "disc" pixel expansion outperforming a "bounding box" approach combined with the need for filtering objects based on size and image-edge location. Importantly, OPTIMAL can be used to assess and integrate with any existing approach to IMC data analysis and, as it creates .FCS files from the segmentation output and allows for single-cell exploration to be conducted using a wide variety of accessible software and algorithms familiar to conventional flow cytometrists.

Distinct lung cell signatures define the temporal evolution of diffuse alveolar damage in fatal COVID-19.

BACKGROUND: Lung damage in severe COVID-19 is highly heterogeneous however studies with dedicated spatial distinction of discrete temporal phases of diffuse alveolar damage (DAD) and alternate lung injury patterns are lacking. Existing studies have also not accounted for progressive airspace obliteration in cellularity estimates. We used an imaging mass cytometry (IMC) analysis with an airspace correction step to more accurately identify the cellular immune response that underpins the heterogeneity of severe COVID-19 lung disease. METHODS: Lung tissue was obtained at post-mortem from severe COVID-19 deaths. Pathologist-selected regions of interest (ROIs) were chosen by light microscopy representing the patho-evolutionary spectrum of DAD and alternate disease phenotypes were selected for comparison. Architecturally normal SARS-CoV-2-positive lung tissue and tissue from SARS-CoV-2-negative donors served as controls. ROIs were stained for 40 cellular protein markers and ablated using IMC before segmented cells were classified. Cell populations corrected by ROI airspace and their spatial relationships were compared across lung injury patterns. FINDINGS: Forty patients (32M:8F, age: 22-98), 345 ROIs and >900k single cells were analysed. DAD progression was marked by airspace obliteration and significant increases in mononuclear phagocytes (MnPs), T and B lymphocytes and significant decreases in alveolar epithelial and endothelial cells. Neutrophil populations proved stable overall although several interferon-responding subsets demonstrated expansion. Spatial analysis revealed immune cell interactions occur prior to microscopically appreciable tissue injury. INTERPRETATION: The immunopathogenesis of severe DAD in COVID-19 lung disease is characterised by sustained increases in MnPs and lymphocytes with key interactions occurring even prior to lung injury is established. FUNDING: UK Research and Innovation/Medical Research Council through the UK Coronavirus Immunology Consortium, Barbour Foundation, General Sir John Monash Foundation, Newcastle University, JGW Patterson Foundation, Wellcome Trust.

Land degradation neutrality: Testing the indicator in a temperate agricultural landscape.

Land degradation directly affects around 25% of land globally, undermining progress on most of the UN Sustainable Development Goals (SDG), particularly target 15.3. To assess land degradation, SDG indicator 15.3.1 combines sub-indicators of productivity, soil carbon and land cover. Over 100 countries have set Land Degradation Neutrality (LDN) targets. Here, we demonstrate application of the indicator for a well-established agricultural landscape using the case study of Great Britain. We explore detection of degradation in such landscapes by: 1) transparently evaluating land cover transitions; 2) comparing assessments using global and national data; 3) identifying misleading trends; and 4) including extra sub-indicators for additional forms of degradation. Our results demonstrate significant impacts on the indicator both from the land cover transition evaluation and choice or availability of data. Critically, we identify a misleading improvement trend due to a trade-off between improvement detected by the productivity sub-indicator, and 30-year soil carbon loss trends in croplands (11% from 1978 to 2007). This carbon loss trend would not be identified without additional data from Countryside Survey (CS). Thus, without incorporating field survey data we risk overlooking the degradation of regulating and supporting ecosystem services (linked to soil carbon), in favour of signals from improving provisioning services (productivity sub-indicator). Relative importance of these services will vary between socioeconomic contexts. Including extra sub-indicators for erosion or critical load exceedance, as additional forms of degradation, produced a switch from net area improving (9%) to net area degraded (58%). CS data also identified additional degradation for soil health, including 44% arable soils exceeding bulk density thresholds and 35% of CS squares exceeding contamination thresholds for metals.

Decreasing Technology Burdens to Bedside Staff Through the Introduction of a Patient Technology Technician Role: A Quality Improvement Project.

With increased technology integration into health care, the focus and time of nurses are often shifting toward technology and away from direct patient care. The goal of this quality improvement project was to implement a patient technology technician role on 3 acute care units in order to reduce the time burden of technology to nurses. During this quality improvement project, the patient technology technician role focused on addressing technology issues and ensured adequate, functioning technology supplies were available on nursing units. Outcomes assessed included self-reporting of the technology time burden, the satisfaction associated with technology, and the impact on telemetry calls from the virtual telemetry monitoring center. In the pretest survey, only 10% to 14% of bedside staff were somewhat satisfied or very satisfied with the time spent managing technology. In the posttest survey, that number increased from 92% to 96%. In the pretest survey, 64% to 83% of bedside staff reported often or frequently fixing, managing, or looking for technology. In the posttest survey that number decreased from 4% to 16%. There was also a reduction in telephone calls from the virtual telemetry monitoring center after implementation. The patient technology technician role was able to successfully relieve the technology time burden for bedside staff.

Synovial Macrophages in Osteoarthritis: The Key to Understanding Pathogenesis?

Effective treatment of osteoarthritis (OA) remains a huge clinical challenge despite major research efforts. Different tissues and cell-types within the joint contribute to disease pathogenesis, and there is great heterogeneity between patients in terms of clinical features, genetic characteristics and responses to treatment. Inflammation and the most abundant immune cell type within the joint, macrophages, have now been recognised as possible players in disease development and progression. Here we discuss recent findings on the involvement of synovial inflammation and particularly the role of synovial macrophages in OA pathogenesis. Understanding macrophage involvement may hold the key for improved OA treatments.

Prognostic significance of interleukin-17A-producing colorectal tumour antigen-specific T cells.

BACKGROUND: The T cell cytokine profile is a key prognostic indicator of post-surgical outcome for colorectal cancer (CRC). Whilst TH1 (IFN-γ+) cell-mediated responses generated in CRC are well documented and are associated with improved survival, antigen-specific TH17 (IL-17A+) responses have not been similarly measured. METHODS: We sought to determine the cytokine profile of circulating tumour antigen-(5T4/CEA) specific T cells of 34 CRC patients to address whether antigen-specific IL-17A responses were detectable and whether these were distinct to IFN-γ responses. RESULTS: As with IFN-γ-producing T cells, anti-5T4/CEA TH17 responses were detectable predominantly in early stage (TNM I/II) CRC patients. Moreover, whilst IL-17A was always produced in association with IFN-γ, this release was mainly from two distinct T cell populations rather than by 'dual producing' T cells. Patients mounting both tumour-specific TH1+/TH17+ responses exhibited prolonged relapse-free survival. CONCLUSIONS: Tumour antigen-specific TH17 responses play a beneficial role in preventing post-operative colorectal tumour recurrence.

Embedding best transfusion practice and blood management in neonatal intensive care.

BACKGROUND: Transfusion is a common procedure for neonates receiving intensive care management. Recognising a paucity of patient blood management (PBM) programmes in neonates, we aimed to embed blood management and best transfusion principles in the neonatal intensive care unit (NICU) by aligning local policies, providing targeted education and partnering with parents. METHODS: Practice-based evidence for clinical practice improvement (PBE-CPI) methodology was used. Previous hospital accreditation audits were reviewed and a neonate-specific transfusion audit was developed. Audit was performed at baseline and repeated following the intervention period. NICU clinicians received targeted education in obtaining informed consent, prescription and safe administration of blood components during a 'Blood Month' awareness period. A neonate-specific parent handout about transfusion was developed in partnership with parents. A pilot video demonstrating a shared consent discussion was also developed to assist in the consent process. Parents' knowledge, concerns and feedback regarding transfusion practice was sought at baseline (survey) and on project completion (experience trackers). RESULTS: Neonate-specific baseline transfusion audit showed inconsistent consent, monitoring and documentation processes in neonatal transfusions. Post-targeted education audit showed improvement in these parameters. The targeted PBM and transfusion-related education delivered during 'Blood Month' was well-received by staff. Parents' feedback about the NICU transfusion consenting process was consistently positive. NICU medical and nursing clinicians (n=25) surveyed agreed that the parent handout was well set out, easy to understand and recommended that it be used to complement practice. CONCLUSION: PBE-CPI tools aligned with Australian PBM guidelines for clinicians and parents were well-accepted by clinical stakeholders and were associated with practice improvement in PBM awareness and transfusion consent processes. This PBE-CPI project developed NICU-specific consent information, not previously available, by partnering with parents to ensure quality of care in transfusion practice. Adoption of this also helps to meet accreditation for Australian Blood Management Standards. These strategies and tools translate readily into other NICUs to embed and support best PBM and transfusion practice.

Continuous Renal Replacement Therapy Dosing in Critically Ill Patients: A Quality Improvement Initiative.

RATIONALE & OBJECTIVE: Clinical practice guidelines recommend delivering a continuous renal replacement therapy (CRRT) dose of 20 to 25mL/kg/h. However, practice patterns nationwide are highly variable; this inconsistent prescribing may lead to errors in medication dosing and increase rates of electrolyte and acid-base abnormalities. We describe an initiative to standardize CRRT practice patterns and reduce dosing variability. STUDY DESIGN: Quality improvement study. SETTING & PARTICIPANTS: Adult patients treated with CRRT at the University of Colorado Hospital between January 2016 and October 2017. QUALITY IMPROVEMENT ACTIVITIES: An assessment of the magnitude of the variability in CRRT dosing and the following specific interventions were implemented during the course of 1 year: (1) modification of the electronic medical record (EMR) to include calculated average 24-hour dose in real time, (2) modification of the CRRT procedure note to include comments on dosing, (3) modification of the CRRT order set to display calculations, and (4) yearly educational sessions for renal fellows outlining CRRT-specific dosing targets. OUTCOMES: The primary outcome was weekly percentage of CRRT treatments with an average delivered daily dose of 20 to 25mL/kg/h. Process and balancing outcomes included CRRT flowsheet accuracy, documentation of rates of delivered dose, and nursing satisfaction. ANALYTICAL APPROACH: Rates of weekly CRRT dosing in compliance with national guidelines were determined and used to create run charts showing compliance rates before and after the quality improvement interventions. RESULTS: Among 837 treatments before the intervention, 279 (33%) daily CRRT sessions achieved an average dose of 20 to 25mL/kg/h. Following implementation of interventions, 631 of 952 (66%) treatments achieved this goal. Week-to-week variation in dosing was significantly reduced. LIMITATIONS: A single-center study generating data that may not be generalizable to institutions with different CRRT nursing models or different EMR systems. CONCLUSIONS: Changes to the EMR and documentation templates and education of CRRT providers about dosing were associated with doubling of the rate of appropriate CRRT dosing and reduction in dosing variability.

The Ussing chamber system for measuring intestinal permeability in health and disease.

BACKGROUND: The relationship between intestinal epithelial integrity and the development of intestinal disease is of increasing interest. A reduction in mucosal integrity has been associated with ulcerative colitis, Crohn's disease and potentially could have links with colorectal cancer development. The Ussing chamber system can be utilised as a valuable tool for measuring gut integrity. Here we describe step-by-step methodology required to measure intestinal permeability of both mouse and human colonic tissue samples ex vivo, using the latest equipment and software. This system can be modified to accommodate other tissues. METHODS: An Ussing chamber was constructed and adapted to support both mouse and human tissue to measure intestinal permeability, using paracellular flux and electrical measurements. Two mouse models of intestinal inflammation (dextran sodium sulphate treatment and T regulatory cell depletion using C57BL/6-FoxP3DTR mice) were used to validate the system along with human colonic biopsy samples. RESULTS: Distinct regional differences in permeability were consistently identified within mouse and healthy human colon. In particular, mice showed increased permeability in the mid colonic region. In humans the left colon is more permeable than the right. Furthermore, inflammatory conditions induced chemically or due to autoimmunity reduced intestinal integrity, validating the use of the system. CONCLUSIONS: The Ussing chamber has been used for many years to measure barrier function. However, a clear and informative methods paper describing the setup of modern equipment and step-by-step procedure to measure mouse and human intestinal permeability isn't available. The Ussing chamber system methodology we describe provides such detail to guide investigation of gut integrity.

Quantifying gross vs. net agricultural land use change in Great Britain using the Integrated Administration and Control System.

Land use change has impacts upon many natural processes, and is one of the key measures of anthropogenic disturbance on ecosystems. Agricultural land covers 70% of Great Britain's (GB) land surface and annually undergoes disturbance and change through farming practices such as crop rotation, ploughing and the planting and subsequent logging of forestry. It is important to quantify how much of GB's agricultural land undergoes such changes and what those changes are at an annual temporal resolution. Integrated Administration and Control System (IACS) data give annual snapshots of agricultural land use at the field level, allowing for high resolution spatiotemporal land use change studies at the national scale. Crucially, not only do the data allow for simple net change studies (total area change of a land use, in a specific areal unit) but also for gross change calculations (summation of all changes to and from a land use), meaning that both gains and losses to and from each land use category can be defined. In this study we analysed IACS data for GB from 2005 to 2013, and quantified gross change for over 90% of the agricultural area in GB for the first time. It was found that gross change totalled 63,500 km2 in GB compared to 20,600 km2 of net change, i.e. the real year-on-year change is, on average, three times larger than net change. This detailed information on nature of land use change allows for increased accuracy in modelling the impact of land use change on ecosystem processes and is directly applicable across EU member states, where collection of such survey data is a requirement. The modelled carbon flux associated with gross land use change was at times >100 Gg C y-1 larger than that based on net land use change for some land use transitions.

Low-Dose Cyclophosphamide Induces Antitumor T-Cell Responses, which Associate with Survival in Metastatic Colorectal Cancer.

Purpose: Anticancer T-cell responses can control tumors, but immunosuppressive mechanisms in vivo prevent their function. The role of regulatory T cells (Tregs) in metastatic colorectal cancer is unclear. We have previously shown depletion of Tregs enhances colorectal cancer-specific effector T-cell responses. Low-dose cyclophosphamide targets Tregs in animal models and some human studies; however, the effect of cyclophosphamide in metastatic colorectal cancer is unknown.Experimental Design: Fifty-five patients with metastatic colorectal cancer were enrolled in a phase I/II trial and randomly assigned to receive 2-week-long courses of low-dose (50 mg twice a day) cyclophosphamide or not. The absolute number, phenotype, and antitumor function of peripheral blood-derived lymphocyte subsets were monitored throughout treatment, as well as during 18-month follow-up.Results: Initially, cyclophosphamide reduced proliferation in all lymphocyte subsets; however, a rapid mobilization of effector T cells overcame this decrease, leading to increased absolute T-cell numbers. In contrast, a reduction in proportional and absolute Treg, B-cell, and NK-cell numbers occurred. The expansion and subsequent activation of effector T cells was focused on tumor-specific T cells, producing both granzyme B and IFNγ. Cyclophosphamide-treated patients demonstrating the most enhanced IFNγ+ tumor-specific T-cell responses exhibited a significant delay in tumor progression [HR = 0.29; 95% confidence interval (CI), 0.12-0.69; P = 0.0047), compared with nonresponders and no-treatment controls.Conclusions: Cyclophosphamide-induced Treg depletion is mirrored by a striking boost in antitumor immunity. This study provides the first direct evidence of the benefit of naturally primed T cells in patients with metastatic colorectal cancer. Our results also support the concept that nonmutated self-antigens may act as useful targets for immunotherapies. Clin Cancer Res; 23(22); 6771-80. ©2017 AACR.

Effect of Modified Vaccinia Ankara-5T4 and Low-Dose Cyclophosphamide on Antitumor Immunity in Metastatic Colorectal Cancer: A Randomized Clinical Trial.

IMPORTANCE: The success of immunotherapy with checkpoint inhibitors is not replicated in most cases of colorectal cancer; therefore, different strategies are urgently required. The oncofetal antigen 5T4 is expressed in more than 90% of cases of metastatic colorectal cancer (mCRC). Preliminary data using modified vaccinia Ankara-5T4 (MVA-5T4) in mCRC demonstrated that it safely induced serologic and T-cell responses. OBJECTIVE: To determine whether antitumor immunity in mCRC could be increased using MVA-5T4, metronomic low-dose cyclophosphamide, or a combination of both treatments. DESIGN, SETTING, AND PARTICIPANTS: In this randomized clinical trial, 55 patients with inoperable mCRC and prior stable disease after standard chemotherapy were enrolled at a single center and randomized to watch and wait (n = 9), cyclophosphamide treatment only (n = 9), MVA-5T4 only (n = 19), and a combination of MVA-5T4 and cyclophosphamide (n = 18). Patients were enrolled and treated from July 9, 2012, through February 8, 2016, and follow-up was completed on December 13, 2016. Data were analyzed based on intention to treat. INTERVENTIONS: Patients randomized to a cyclophosphamide group received 50 mg twice daily on treatment days 1 to 7 and 15 to 21. Patients randomized to a MVA-5T4 group received an intramuscular injection at a dose of 1 × 109 50% tissue culture infectious dose on treatment days 22, 36, 50, 64, 78, and 106. MAIN OUTCOMES AND MEASURES: The predefined primary end point was the magnitude of anti-5T4 immune responses (5T4-specific T-cell and antibody levels) generated at treatment week 7. Secondary end points included analysis of the kinetics of anti-5T4 responses, progression-free survival (PFS), and overall survival (OS). RESULTS: Fifty-two patients (38 men and 14 women; mean [SD] age, 64.2 [10.1] years) were included in the study analysis. The 5T4-specific antibody immune responses were significantly increased in the MVA-5T4 (83.41 [36.09] relative units [RU]; P = .02) and combination treatment (65.81 [16.68] RU; P = .002) groups compared with no treatment (20.09 [7.20] RU). Cyclophosphamide depleted regulatory T cells in 24 of 27 patients receiving MVA-5T4, independently prolonging PFS (5.0 vs 2.5 months; hazard ratio [HR], 0.48; 95% CI, 0.21-1.11; P = .09). MVA-5T4 doubled baseline anti-5T4 responses in 16 of 35 patients, resulting in significantly prolonged PFS (5.6 vs 2.4 months; HR, 0.21; 95% CI, 0.09-0.47; P < .001) and OS (20.0 vs 10.3 months; HR, 0.32; 95% CI, 0.14-0.74; P = .008). No grade 3 or 4 adverse events were observed. CONCLUSIONS AND RELEVANCE: This initial randomized clinical immunotherapy study demonstrates a significant survival benefit in mCRC. Prior depletion of regulatory T cells by cyclophosphamide did not increase immune responses generated by MVA-5T4 vaccination; however, cyclophosphamide and MVA-5T4 each independently induced beneficial antitumor immune responses, resulting in prolonged survival without toxic effects. Larger clinical trials are planned to further validate these data. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN54669986.

L-selectin Is Essential for Delivery of Activated CD8(+) T Cells to Virus-Infected Organs for Protective Immunity.

Cytotoxic CD8(+) T lymphocytes play a critical role in the host response to infection by viruses. The ability to secrete cytotoxic chemicals and cytokines is considered pivotal for eliminating virus. Of equal importance is how effector CD8(+) T cells home to virus-infected tissues. L-selectin has not been considered important for effector T cell homing, because levels are low on activated T cells. We report here that, although L-selectin expression is downregulated following T cell priming in lymph nodes, L-selectin is re-expressed on activated CD8(+) T cells entering the bloodstream, and recruitment of activated CD8(+) T cells from the bloodstream into virus-infected tissues is L-selectin dependent. Furthermore, L-selectin on effector CD8(+) T cells confers protective immunity to two evolutionally distinct viruses, vaccinia and influenza, which infect mucosal and visceral organs, respectively. These results connect homing and a function of virus-specific CD8(+) T cells to a single molecule, L-selectin.

Fifth-grade children's daily experiences of peer victimization and negative emotions: moderating effects of sex and peer rejection.

This study examined the relations of fifth-grade children's (181 boys and girls) daily experiences of peer victimization with their daily negative emotions. Children completed daily reports of peer victimization and negative emotions (sadness, anger, embarrassment, and nervousness) on up to eight school days. The daily peer victimization checklist was best represented by five factors: physical victimization, verbal victimization, social manipulation, property attacks, and social rebuff. All five types were associated with increased negative daily emotions, and several types were independently linked to increased daily negative emotions, particularly physical victimization. Girls demonstrated greater emotional reactivity in sadness to social manipulation than did boys, and higher levels of peer rejection were linked to greater emotional reactivity to multiple types of victimization. Sex and peer rejection also interacted, such that greater rejection was a stronger indicator of emotional reactivity to victimization in boys than in girls.

Patient blood management -- the GP's guide.

BACKGROUND: There is accumulating evidence of a strong association between blood transfusion and adverse patient outcomes. Patient blood management aims to achieve improved patient outcomes by avoiding unnecessary exposure to blood products through effective conservation and management of a patient's own blood. OBJECTIVE: To introduce the general practitioner's role in patient blood management. DISCUSSION: There are a number of ways in which GPs can contribute to patient blood management, particularly in the care of patients scheduled for elective surgery. These include awareness, identification, investigation and management of patients with or at risk of anaemia; assessment of the adequacy of iron stores in patients undergoing planned procedures in which substantial blood loss is anticipated; awareness and assessment of medications and complementary medicines that might increase bleeding risk; and awareness of and ability to discuss with patients, the possible risks associated with blood transfusion and alternatives that may be available.

Stream water hydrochemistry as an indicator of carbon flow paths in Finnish peatland catchments during a spring snowmelt event.

Extreme hydrological events are known to contribute significantly to total annual carbon export, the largest of which in Arctic and boreal catchments is spring snowmelt. Whilst previous work has quantified the export of carbon during snowmelt, the source of the carbon remains unclear. Here we use cation hydrochemistry to trace the primary flowpaths which govern the export of carbon during the snowmelt period; specifically we aim to examine the importance of snowpack meltwater to catchment carbon export. The study was carried out in two forested peatland (drained and undrained) catchments in Eastern Finland. Both catchments were characterised by base-poor stream water chemistry, with cation concentrations generally decreasing in response to increasing discharge. Streamflow during the snowmelt period was best described as a mixture of three sources: pre-event water, snowpack meltwater and a third dilute component we attribute to the upper snow layer which was chemically similar to recent precipitation. Over the study period, pre-event water contributed 32% and 43% of the total stream runoff in Välipuro (undrained) and Suopuro (drained), respectively. The results also suggest a greater near-surface throughflow component in Suopuro, the drained catchment, prior to snowmelt. CO(2) and DOC concentrations correlated positively with cation concentrations in both catchments indicating a common, peat/groundwater flowpath. CH(4) concentrations were significantly higher in the drained catchment and appeared to be transported in near-surface throughflow. Meltwater from the snowpack represented an important source of stream water CO(2) in both catchments, contributing up to 49% of total downstream CO(2) export during the study period. We conclude that the snowpack represents a potentially important, and often overlooked, transient carbon store in boreal snow-covered catchments.

Diagnosis and management of iron deficiency anaemia: a clinical update.

Iron deficiency anaemia (IDA) remains prevalent in Australia and worldwide, especially among high-risk groups. IDA may be effectively diagnosed in most cases by full blood examination and serum ferritin level. Serum iron levels should not be used to diagnose iron deficiency. Although iron deficiency may be due to physiological demands in growing children, adolescents and pregnant women, the underlying cause(s) should be sought. Patients without a clear physiological explanation for iron deficiency (especially men and postmenopausal women) should be evaluated by gastroscopy/colonoscopy to exclude a source of gastrointestinal bleeding, particularly a malignant lesion. Patients with IDA should be assessed for coeliac disease. Oral iron therapy, in appropriate doses and for a sufficient duration, is an effective first-line strategy for most patients. In selected patients for whom intravenous (IV) iron therapy is indicated, current formulations can be safely administered in outpatient treatment centres and are relatively inexpensive. Red cell transfusion is inappropriate therapy for IDA unless an immediate increase in oxygen delivery is required, such as when the patient is experiencing end-organ compromise (eg, angina pectoris or cardiac failure), or IDA is complicated by serious, acute ongoing bleeding. Consensus methods for administration of available IV iron products are needed to improve the utilisation of these formulations in Australia and reduce inappropriate transfusion. New-generation IV products, supported by high-quality evidence of safety and efficacy, may facilitate rapid administration of higher doses of iron, and may make it easier to integrate IV iron replacement into routine care.

Surgical management of placenta accreta: a cohort series and suggested approach.

OBJECTIVE: The purpose of this study was to describe the use of a staged procedure that involved femoral artery catheterization, classic cesarean section delivery, and uterine and placental embolization before hysterectomy for placenta accreta. STUDY DESIGN: We conducted a cohort study of retrospective and prospective data from cases of histologically identified placenta accreta at a tertiary teaching hospital with access to interventional radiology. RESULTS: Twenty-six cases of placenta accreta were identified histologically (7 accretas, 5 incretas, and 14 percretas); 8 cases were successful staged embolization procedures. These cases had significant reductions in blood loss (553 vs 4517 mL; P = .0001), need for transfusion (2 vs 16; P = .001), and units of blood transfused (0.5 vs 7.9; P = .0013). The total operation time was no different between the 2 groups, but there was a longer length of anesthesia (2.7 vs 6.6 hours; P = .0001). There were nonsignificant reductions in admission to the intensive care unit and length of hospital stay. CONCLUSION: We found that the successful use of a staged embolization hysterectomy procedure for placenta accreta is associated with decreased maternal morbidity.