Evaluation of iron deficiency anaemia in tertiary hospital settings: room for improvement?

BACKGROUND: Iron deficiency anaemia (IDA) is a marker of occult blood loss from gastrointestinal (GI) lesions and requires thorough GI evaluation. AIM: This study aimed to determine frequency and findings of GI endoscopy in patients with IDA attending a tertiary hospital, and associations of endoscopy with patient and clinician-related factors and results of faecal occult blood tests (FOBT). METHODS: Retrospective audit of 621 subjects identified with definite and probable IDA (serum ferritin ≤ 15 ug/L and 16-50 µg/L respectively) between 1 January 2006 and 31 December 31 2008. Subjects were analysed as males >18 years and females ≥ 45 years of age with definite (group A, n= 180) or probable (group B, n= 353) IDA, and females <45 years of age with definite or probable IDA (group C, n= 88). RESULTS: Endoscopy of any type was documented in 310 (50%) of patients with oesophagogastroduodenal endoscopy, and colonoscopy rates being significantly higher in group A patients (61% and 56% respectively) than in group B (39%, 37%) and group C (30%, 31%; P ≤ 0.01 for all comparisons). Endoscopy rates ranged from 96% of patients seeing gastroenterologists to 31% of those seeing nephrologists. In patients undergoing colonoscopy, cancer and high-risk adenomas were detected in 51 patients (20%), ranging from 27/100 (27%) of group A, 23/130 (18%) of group B and 1/27 (4%) of group C. Lesion prevalence was similar (19-24%) regardless of whether FOBT yielded positive or negative results or had not been performed. CONCLUSIONS: Almost one in two patients with IDA were not documented as undergoing GI endoscopy. More intense guideline promulgation, improved endoscopy access and ongoing practice audits are required to improve endoscopy rates.

Anti-N-methyl-D-aspartate receptor antibody limbic encephalitis.

We report the case of a 57-year-old woman who developed acute psychiatric symptoms, behavioural disturbances, insomnia and dystonia resembling a catatonic state. During the course of her illness she developed hypoventilation and required monitoring in the intensive care unit. Her serum and cerebrospinal fluid showed antibodies to the NR1/NR2 heteromers of the N-methyl-D-aspartate receptor (NMDAR). Anti-NMDAR encephalitis is a severe form of autoimmune encephalitis, which has only recently been described in the published work. Most patients improve with immunosuppressive treatment. Raising awareness of this rare but increasingly reported condition is important, as it is responsive to treatment and potentially reversible.