Variability in the clinical management of iron deficiency anaemia in older adults: results from a survey of UK specialists in the care of older people.

BACKGROUND: Iron deficiency anaemia in older adults is common, but its management presents unique challenges in diagnosis and management. Little is known about compliance with current best practice guidelines. METHODS: We undertook an online survey of physician members of the British Geriatrics Society to ascertain how they managed older patients with potential iron deficiency anaemia. RESULTS: There were 141 respondents (96% from UK). Almost a third indicated they would accept haemoglobin levels <100 g/dl without further investigation. A quarter said they would only occasionally or never check ferritin levels. Only 30% would sometimes or always use parenteral iron when oral supplements were not tolerated. CONCLUSIONS: Responses suggest a high level of variation in clinical practice and low adherence to best practice guidelines. Possible explanations include an inadequate evidence base to guide management and a lack of knowledge on the challenges of managing iron deficiency anaemia in this population.

Cross-sectional relationship between haemoglobin concentration and measures of physical and cognitive function in an older rural South African population.

BACKGROUND: Age cohort differences in haemoglobin concentrations and associations with physical and cognitive performance among populations of lower income and middle-income countries have not previously been described. We examined the association between these factors among older men and women in rural South Africa. METHODS: We analysed cross-sectional data from a population-based study of rural South African men and women aged 40 and over (n=4499), with data drawn from questionnaire responses, a cognitive battery, objective physical function tests and blood tests. Anaemia was defined as a haemoglobin concentration <12 g/dL for women and <13 g/dL for men. We related haemoglobin concentrations to each of age, grip strength, walk speed and a latent cognitive function z-score for men and women separately. We used unadjusted correlations and linear models to adjust for comorbidities and inflammation. RESULTS: In total, 1042 (43.0%) women and 833 (40.1%) men were anaemic. Haemoglobin concentrations were inversely correlated with age for men but not for women; in adjusted analyses, haemoglobin was 0.3 g/dL lower per decade older for men (95% CI 0.2 to 0.4 g/dL). In adjusted analyses, haemoglobin concentration was independently associated with grip strength in women (B=0.391, 95% CI 0.177 to 0.605), but this did not reach significance in men (B=0.266, 95% CI -0.019 to 0.552); no associations were observed between haemoglobin levels and walk speed or cognitive score. CONCLUSIONS: Anaemia was prevalent in this study population of middle-aged and older, rural South African adults, but in contrast to high-income countries, it was not associated with poor physical or cognitive function. Our findings need to be replicated in other populations.

Targeting, Monitoring and Effect of Oral Iron Therapy on Haemoglobin Levels in Older Patients Discharged to Primary Care from Inpatient Rehabilitation: A Cohort Study Using Routinely Collected Data.

BACKGROUND: Oral iron is commonly prescribed to older patients with suspected or confirmed iron-deficiency anaemia; however, few studies have examined the effectiveness of oral iron therapy in the real world in this population. We therefore determined the prevalence of iron deficiency in older people prescribed oral iron, examined the response mounted to therapy and ascertained predictors of response to oral iron. METHODS: We analysed a routinely collected, linked dataset from older patients who had undergone inpatient rehabilitation between 1999 and 2011. An initial analysis examined patients within this cohort who were prescribed iron after rehabilitation and derived three groups based upon their ferritin and transferrin indices: probably, possibly and not iron deficient. A second analysis compared pre- and post-treatment haemoglobin to determine the degree of response to iron therapy across each category of deficiency. Finally, patient demographics, linked biochemistry data and comorbid disease based on International Classification of Disease (ICD-10) codes from previous hospital admissions were used in regression modelling to evaluate factors affecting response to therapy. RESULTS: A total of 490 patients were prescribed oral iron within 90 days of rehabilitation discharge. Of these, 413 (84 %) had iron indices performed; 94 (23 %) were possibly deficient, 224 (54 %) were probably deficient, and 95 (23 %) were not deficient. Of the 490 patients, 360 had both pre- and post-treatment haemoglobin data and iron indices; probably deficient patients mounted a slightly greater response to oral iron (17 vs. 12 g/L for not deficient; p < 0.05). Only pre-treatment haemoglobin, mean cell volume and lower gastrointestinal pathology were significant predictors of a response to oral iron therapy. Notably, acid-suppressant use was not a predictor of response. CONCLUSION: We conclude that many older patients are exposed to oral iron without good evidence of either iron deficiency or a significant response to therapy.

PML isoforms in response to arsenic: high-resolution analysis of PML body structure and degradation.

Arsenic is a clinically effective treatment for acute promyelocytic leukaemia (APL) in which the promyelocytic leukaemia (PML) protein is fused to retinoic receptor alpha (RARα). PML-RARα is degraded by the proteasome by a SUMO-dependent, ubiquitin-mediated pathway in response to arsenic treatment, curing the disease. Six major PML isoforms are expressed as a result of alternative splicing, each of which encodes a unique C-terminal region. Using a system in which only a single EYFP-linked PML isoform is expressed, we demonstrate that PMLI, PMLII and PMLVI accumulate in the cytoplasm following arsenic treatment, whereas PMLIII, PMLIV and PMLV do not. 3D structured illumination was used to obtain super-resolution images of PML bodies, revealing spherical shells of PML along with associated SUMO. Arsenic treatment results in dramatic isoform-specific changes to PML body ultrastructure. After extended arsenic treatment most PML isoforms are degraded, leaving SUMO at the core of the nuclear bodies. A high-content imaging assay identifies PMLV as the isoform most readily degraded following arsenic treatment, and PMLIV as relatively resistant to degradation. Immunoprecipitation analysis demonstrates that all PML isoforms are modified by SUMO and ubiquitin after arsenic treatment, and by using siRNA, we demonstrate that arsenic-induced degradation of all PML isoforms is dependent on the ubiquitin E3 ligase RNF4. Intriguingly, depletion of RNF4 results in marked accumulation of PMLV, suggesting that this isoform is an optimal substrate for RNF4. Thus the variable C-terminal domain influences the rate and location of degradation of PML isoforms following arsenic treatment.