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1.  Maternal Hemoglobin Concentration and Pregnancy Outcome: A Study of the Effects of Elevation in El Alto, Bolivia 
Iron-deficiency anemia is often under-diagnosed in developing countries, specifically in pregnant populations in regions of high altitude. Hemoglobin levels are not consistently adjusted for elevation, and therefore many anemic patients are left undiagnosed. The purpose of this study was to incorporate current parameters for diagnosing anemia in pregnancy at high altitudes, and to evaluate the effects of appropriately adjusted hemoglobin concentrations on pregnancy outcome. A few studies have examined the effect of elevation on hemoglobin status, and other studies have considered the effects of anemia of pregnancy; however, there is a lack of data demonstrating that altitude-adjusted hemoglobin levels accurately predict pregnancy outcome. Using the Student t-Test, multiple linear regression, and ANOVA statistical analyses, various factors of pregnancy outcome were compared between anemic and non-anemic groups, as defined by hemoglobin cut-off levels adjusted for trimester of pregnancy and altitude. When appropriate adjustments were used, maternal anemia was associated with lower infant Apgar scores at both one minute and five minutes after birth, as well as complication of labor, lower gestational age at birth, and higher parity. This study demonstrates the importance of altitude and trimester specific adjustments to maternal hemoglobin levels in order to accurately diagnose anemia in pregnancy. In addition, a clear correlation is seen between maternal hemoglobin level and pregnancy outcome.
PMCID: PMC3296152  PMID: 22399871
Iron-Deficiency Anemia; Pregnancy; Bolivia; Elevation; Altitude; Hemoglobin
2.  Evaluation of a portable hemoglobin photometer in pregnant women in a high altitude area: a pilot study 
BMC Public Health  2009;9:228.
Background
Anemia is a widespread public health problem associated with an increased risk of morbidity and mortality, especially in pregnant women. This study examined the agreement between a portable hemoglobin photometer and a laboratory analyzer in determining hemoglobin level in pregnant women.
Methods
This study recruited 69 pregnant women in Tibet, China. Capillary blood samples were taken to measure hemoglobin concentration using the hemoglobin photometer and the laboratory analyzer. Limit of agreement, concordance and intraclass correlation coefficient were used to evaluate the agreement. Laboratory measurement was considered as the standard reference method. Sensitivity and specificity were calculated to assess the error in screening for anemia.
Results
Mean difference between the two methods was -2.1 g/l. wide 95% limits of agreement were found (-22.6 g/l to 18.4 g/l). The intraclass correlation coefficient was 0.795, and concordance correlation coefficient was 0.793. Sensitivity and specificity were 94.9% and 76.7% respectively. Positive predictive value was 84.1%, and negative predictive value was 92.0%.
Conclusion
This hemoglobin photometer is not recommended for determining hemoglobin concentration in pregnancy in a high altitude area.
doi:10.1186/1471-2458-9-228
PMCID: PMC2717084  PMID: 19591672
3.  Determinants of anemia in postpartum HIV-negative women in Dar es Salaam, Tanzania 
OBJECTIVE
The determinants of anemia during both pregnancy and postpartum recovery remain incompletely understood in sub-Saharan African women.
SUBJECTS/METHODS
In a prospective cohort study among pregnant women, we assessed dietary, biochemical, anthropometric, infectious and sociodemographic factors at baseline. In multivariate Cox proportional hazards models, we examined predictors of incident anemia (hemoglobin <11 g/dl) and iron deficiency anemia (anemia plus mean corpuscular volume <80 fL), and recovery from anemia and iron deficiency anemia through 18 months postpartum at antenatal clinics in Dar es Salaam, Tanzania between 2001 and 2005. A total of 2364 non-anemic pregnant women and 4884 anemic women were enrolled between 12 and 27 weeks of gestation.
RESULTS
In total, 292 women developed anemia during the postpartum period and 165 developed iron deficiency anemia, whereas 2982 recovered from baseline anemia and 2044 from iron deficiency anemia. Risk factors for postpartum anemia were delivery complications (RR 1.6, 95% confidence interval (CI) 1.13, 2.22) and low postpartum CD4 cell count (RR 1.73, 95% CI 0.96, 3.17). Iron/folate supplementation during pregnancy had a protective relationship with the incidence of iron deficiency anemia. Absence of delivery complications, education status and iron/folate supplementation were positively associated with time to recovery from iron deficiency.
CONCLUSION
Maternal nutritional status during pregnancy, prenatal iron/folate supplementation, perinatal care, and prevention and management of infections, such as malaria, are modifiable risk factors for the occurrence of, and recovery from, anemia.
doi:10.1038/ejcn.2013.71
PMCID: PMC3775569  PMID: 23612515
anemia; postpartum; iron deficiency; pregnancy
4.  Anemia prevalence and risk factors in pregnant women in an urban area of Pakistan 
Food and nutrition bulletin  2008;29(2):132-139.
Background.
Anemia affects almost two-thirds of pregnant women in developing countries and contributes to maternal morbidity and mortality and to low birthweight.
Objective.
To determine the prevalence of anemia and the dietary and socioeconomic factors associated with anemia in pregnant women living in an urban community setting in Hyderabad, Pakistan.
Methods.
This was a prospective, observational study of 1,369 pregnant women enrolled at 20 to 26 weeks of gestation and followed to 6 weeks postpartum. A blood sample was obtained at enrollment to determine hemoglobin levels. Information on nutritional knowledge, attitudes, and practice and dietary history regarding usual food intake before and during pregnancy were obtained by trained interviewers within 1 week of enrollment.
Results.
The prevalence of anemia (defined by the World Health Organization as hemoglobin < 11.0 g/dL) in these subjects was 90.5%; of these, 75.0% had mild anemia (hemoglobin from 9.0 to 10.9 g/dL) and 14.8% had moderate anemia (hemoglobin from 7.0 to 8.9 g/dL). Only 0.7% were severely anemic (hemoglobin < 7.0 g/dL). Nonanemic women were significantly taller, weighed more, and had a higher body mass index. Multivariate analysis after adjustment for education, pregnancy history, iron supplementation, and height showed that drinking more than three cups of tea per day before pregnancy (adjusted prevalence odds ratio [aPOR], 3.2; 95% confidence interval [CI], 1.3 to 8.0), consumption of clay or dirt during pregnancy (aPOR, 3.7; 95% CI, 1.1 to 12.3), and never consuming eggs or consuming eggs less than twice a week during pregnancy (aPOR, 1.7; 95% CI, 1.1 to 2.5) were significantly associated with anemia. Consumption of red meat less than twice a week prior to pregnancy was marginally associated with anemia (aPOR, 1.2; 95% CI, 0.8 to 1.8) but was significantly associated with lower mean hemoglobin concentrations (9.9 vs. 10.0 g/dL, p = .05) during the study period. A subanalysis excluding women with mild anemia found similar associations to those of the main model, albeit even stronger.
Conclusions.
A high percentage of women at 20 to 26 weeks of pregnancy had mild to moderate anemia. Pica, tea consumption, and low intake of eggs and red meat were associated with anemia. Women of childbearing age should be provided nutritional education regarding food sources of iron, especially prior to becoming pregnant, and taught how food choices can either enhance or interfere with iron absorption.
PMCID: PMC3917507  PMID: 18693477
Anemia; developing countries; pregnancy
5.  Magnitude of Anemia and Associated Risk Factors among Pregnant Women Attending Antenatal Care in Shalla Woreda, West Arsi Zone, Oromia Region, Ethiopia 
Background
Anemia during pregnancy is a common problem in developing countries and affects both the mother's and her child's health. The main objective of this study was to determine the prevalence of and the factors associated with anemia among pregnant women.
Methods
Facility based cross-sectional study design was conducted from June to August, 2011 on 374 pregnant women. Mothers who came for ANC during the study period and who met the inclusion criteria were interviewed and a capillary blood sample was taken. Hemoglobin level was determined by using HemoCue photometer, and interviewer administered questionnaire was used to collect data. Data were cleaned, coded and fed into SPSS version 16.0 for analysis.
Result
The mean hemoglobin concentration was 12.05±1.5 g/dl and prevalence of anemia was 36.6%. Family sizes (COR=2.67, CI (1.65, 4.32), third trimester (COR=1.45, CI (1.11, 2.23), meat consumption <1x/wk (COR=3.47, CI (1.58, 7.64) and pica (COR=2.33, CI (1.52, 3.58) were significantly associated with anemia. Having five or more children (AOR=5.2, CI [1.29, 21.09]), intake of vegetables and fruits less than once per day (AOR= 6.7, CI [2.49, 17.89]), intake of tea always after meal (AOR = 12.83.CI [45-28.9]), and recurrence of illness during pregnancy (AOR=7.3, CI [2.12–25.39]) were factors associated with anemia.
Conclusion
This study showed that anemia is a moderate public health problem. Less frequent meat and vegetable consumption, parity ≥5 are risk factors for anemia. Therefore, reducing parity, taking balanced diet and use of mosquito nets during pregnancy are recommended.
PMCID: PMC3742894  PMID: 23950633
Hemoglobin; Anemia; Pregnancy; ANC
6.  Comparison of HemoCue® hemoglobin-meter and automated hematology analyzer in measurement of hemoglobin levels in pregnant women at Khartoum hospital, Sudan 
Diagnostic Pathology  2012;7:30.
Background
Assessment of hemoglobin is one of the most reliable indicators for anemia, and is widely used to screen for anemia among pregnant women. The HemoCue® has been widely used for as a point-of-care device for hemoglobin estimation in health facilities. Previous studies showed contradictory results regarding the accuracy of HemoCue®.
Methods
This was a hospital-based cross sectional study carried- out among pregnant women at Khartoum hospital in Sudan to find out whether the measurement of hemoglobin concentration by HemoCue® using venous or capillary samples was comparable to that of the automated hematology analyzer as standard. Bland and Altman method was used to compare the measurements with an acceptable difference of ± 1.0 g/dl.
Results
Among the 108 subjects in this study the mean (SD) level of hemoglobin level using HemoCue® venous sample, HemoCue® capillary sample and automated hematology analyzer were 12.70 (1.77), 12.87 (2.04) and 11.53 (1.63) g/dl, respectively. Although the correlations between the measurements were all significant there was no agreement between HemoCue® and automated hematology analyzer. The bias + SD (limits of agreement) for HemoCue® venous versus hematology analyzer was 1.17 ± 1.57 (-1.97, 4.31) g/dl, HemoCue® capillary versus hematology analyzer was 1.34 ± 1.85 (-2.36, 5.04) g/dl, and HemoCue® venous versus HemoCue® capillary samples was 017 ± 1.90 and (3.97-3.63) g/dl.
Conclusion
Hemoglobin concentration assessment by HemoCue® using either venous or capillary blood samples has shown unacceptable agreement with automated hematology analyzer.
Virtual slides
The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/8797022296725036
doi:10.1186/1746-1596-7-30
PMCID: PMC3342090  PMID: 22436620
7.  Population level determinants of acute mountain sickness among young men: a retrospective study 
BMC Public Health  2011;11:740.
Background
Many visitors, including military troops, who enter highland regions from low altitude areas may suffer from acute mountain sickness (AMS), which negatively impacts workable man-hours and increases healthcare costs. The aim of this study was to evaluate the population level risk factors and build a multivariate model, which might be applicable to reduce the effects of AMS on Chinese young men traveling to this region.
Methods
Chinese highland military medical records were used to obtain data of young men (n = 3727) who entered the Tibet plateau between the years of 2006-2009. The relationship between AMS and travel profile, demographic characteristics, and health behaviors were evaluated by logistic regression. Univariate logistic models estimated the crude odds ratio. The variables that showed significance in the univariate model were included in a multivariate model to derive adjusted odds ratios and build the final model. Data corresponding to odd and even years (2 subsets) were analyzed separately and used in a simple cross-validation.
Results
Univariate analysis indicated that travel profile, prophylactic use, ethnicity, and province of birth were all associated with AMS in both subsets. In multivariate analysis, young men who traveled from lower altitude (600-800 m vs. 1300-1500 m, adjusted odds ratio (AOR) = 1.32-1.44) to higher altitudes (4100-4300 m vs. 2900-3100 m, AOR = 3.94-4.12; 3600-3700 m vs. 2900-3100 m, AOR = 2.71-2.74) by air or rapid land transport for emergency mission deployment (emergency land deployment vs. normal land deployment, AOR = 2.08-2.11; normal air deployment vs. normal land deployment, AOR = 2.00-2.20; emergency air deployment vs. normal land deployment, AOR = 2.40-3.34) during the cold season (cold vs. warm, AOR = 1.25-1.28) are at great risk for developing AMS. Non-Tibetan male soldiers (Tibetan vs. Han, AOR = 0.03-0.08), born and raised in lower provinces (eastern vs. northwestern, AOR = 1.32-1.39), and deployed without prophylaxis (prophylactic drug vs. none, AOR = 0.75-0.76), also represented a population at significantly increased risk for AMS. The predicted model was built; the area under receiver operating characteristic curve was 0.703.
Conclusion
Before a group of young men first enter a high altitude area, it is important that a health service plan should be made referring to the group's travel profile and with respect to young men's ethnicity and province of birth. Low-cost Chinese traditional prophylactic drugs might have some effect on decreasing the risk of AMS, although this needs further verification.
doi:10.1186/1471-2458-11-740
PMCID: PMC3190355  PMID: 21955882
acute mountain sickness; risk factor; high altitude; young men; logistic regression; retrospective study
8.  Maternal and Perinatal Outcomes in Second Hemoglobin Measurement in Nonanemic Women at First Booking: Effect of Altitude of Residence in Peru 
ISRN Obstetrics and Gynecology  2012;2012:368571.
Objective. To determine changes in hemoglobin concentration at second measurements after a normal hemoglobin concentration was detected at first booking during pregnancy at low and at high altitudes. Methods. This is a secondary analysis of a large database obtained from the Perinatal Information System in Peru which includes 379,816 pregnant women and their babies from 43 maternity units in Peru. Results. Most women remained with normal hemoglobin values at second measurement (75.1%). However, 21.4% of women became anemic at the second measurement. In all, 2.8% resulted with moderate/severe anemia and 3.5% with erythrocytosis (Hb>14.5 g/dL). In all cases Hb was higher as altitude increased. Risk for moderate/severe anemia increased associated with higher gestational age at second measurement of hemoglobin, BMI <19.9 kg/m2, living without partner, <5 antenatal care visits, first parity, multiparity, and preeclampsia. Lower risk for moderate/severe anemia was observed with normal high Hb level at first booking living at moderate and high altitude, and high BMI. Conclusion. Prevalence of anemia increases as pregnancy progress, and that a normal value at first booking may not be considered sufficient as Hb values should be observed throughout pregnancy. BMI was a risk for anemia in a second measurement.
doi:10.5402/2012/368571
PMCID: PMC3345214  PMID: 22577573
9.  Iron Deficiency Anemia in Pregnancy: Intravenous Versus Oral Route 
Objectives
The aim of this study was to compare the efficacy and safety of intravenous iron with oral iron in the treatment of iron deficiency anemia of pregnancy.
Methods
A randomized experimental study was conducted at K. J. Somaiya Hospital involving 200 pregnant women with iron deficiency anemia. In the intravenous group iron dose was calculated from: Total iron dose required (mg) = 2.4 × weight kg × target hemoglobin − actual hemoglobin) g/dl + 500.   Target hemoglobin was set at 12 g/dl. In the oral group patients received 200 mg oral ferrous ascorbate daily. Hemoglobin and serum ferritin were reviewed at 2, 4, and 6 weeks. Paired and independent t test was applied.
Results
The change in hemoglobin and ferritin levels from baseline was significantly higher in the intravenous group than the oral group at each measurement (P = 0.000).
Conclusion
Intravenous iron elevates hemoglobin and restores iron stores faster than oral iron, with no severe adverse reactions.
doi:10.1007/s13224-012-0222-0
PMCID: PMC3444565  PMID: 23730037
Iron deficiency anemia; Hemoglobin; Serum ferritin; Iron sucrose; Oral ferrous ascorbate
10.  Prevalence of HIV and anemia among pregnant women 
Background:
Human immunodeficiency virus (HIV) prevalence is high among rural dwellers and pregnant women.
Aims:
This study aims to determine the prevalence of HIV and anemia among pregnant women attending antenatal clinic in rural community of Okada, Edo State, Nigeria.
Patients and Methods:
Anticoagulated blood and sera samples were obtained from 480 women consisting of 292 pregnant and 188 non-pregnant women. Antibodies to HIV were detected in the sera samples and hemoglobin concentration of the anticoagulated blood specimens were determined using standard techniques. Anemia was defined as hemoglobin concentration <11g/dl for pregnant women and <12g/dl for non-pregnant women.
Results:
Pregnancy was not a risk factor for acquiring HIV infection (pregnant vs. non-pregnant: 10.2% vs. 13.8%; OR=0.713, 95% CI=0.407, 1.259, P = 0.247). The prevalence of HIV was significantly (P = 0.005 and P = 0.025) higher in the age group 10-20 years and 21 – 30 years among pregnant and non-pregnant women respectively. Pregnancy was a risk factor for acquiring anemia (OR=1.717, 95% CI=1.179, 2.500, P = 0.006). Only the age of pregnant women significantly (P = 0.004) affected the prevalence of anemia inversely.
Conclusion:
The prevalence of HIV and anemia among pregnant women were 10.2% and 49.3% respectively. Pregnancy was associated with anemia. Interventions by appropriate agencies are advocated to reduce associated sequelae.
doi:10.4297/najms.2011.3548
PMCID: PMC3271417  PMID: 22363076
Pregnancy; HIV; anemia; rural community; Nigeria
11.  Khat Chewing and Restrictive Dietary Behaviors Are Associated with Anemia among Pregnant Women in High Prevalence Rural Communities in Eastern Ethiopia 
PLoS ONE  2013;8(11):e78601.
Background
Anemia affects a high proportion of pregnant women in the developing countries. Factors associated with it vary in context. This study aimed to determine the prevalence and predictors of anemia among pregnant women in the rural eastern Ethiopia.
Methods
A community-based cross-sectional study was done on 1678 pregnant women who were selected by a cluster random sampling technique. A pregnant woman was identified as anemic if her hemoglobin concentration was <11 g/dl. Data were collected in a community-based setting. Multilevel mixed effect logistic regression was used to determine the adjusted odds ratios (AOR) with 95% confidence intervals (CI) for the predictors of anemia.
Results
Anemia was observed among 737(43.9%) of the 1678 pregnant women studied (95% CI 41.5%–46.3%). After controlling for the confounders, the risk of anemia was 29% higher in the women who chewed khat daily than those who sometimes or never did so (AOR, 1.29; 95% CI, 1.02–1.62). The study subjects with restrictive dietary behavior (reduced either meal size or frequency) had a 39% higher risk of anemia compared to those without restrictive dietary behavior (AOR, 1.39; 95% CI, 1.02–1.88). The risk of anemia was increased by 68% (AOR, 1.68; 95% CI, 1.15–2.47), and 60% (AOR, 1.60; 95% CI, 1.08–2.37) in parity levels of 2 births and 3 births, respectively. Compared to the first trimester, the risk of anemia was higher by two-fold (AOR, 2.09; 95% CI, 1.46–3.00) in the second trimester and by four-fold (AOR, 4.23; 95% CI, 2.97–6.02) in the third trimester.
Conclusion
In this study, two out of five women were anemic. Chewing khat and restrictive dietary habits that are associated with anemia in the setting should be addressed through public education programs. Interventions should also focus on the women at higher parity levels and those who are in advanced stages of pregnancy.
doi:10.1371/journal.pone.0078601
PMCID: PMC3817221  PMID: 24223828
12.  Iron, folate and vitamin B12 levels in first trimester pregnancies in the Southwest region of Turkey 
Objective
Iron, folate and vitamin B12 play important roles in the healthy development of the fetus in pregnancy. Preconceptional levels of these micronutrients is influenced by dietary habits. The purpose of this study was to investigate the status of iron, vitamin B12 and folate in first trimester pregnancies in the southwest region of Turkey where the Mediterranean Cuisine, rich in fresh fruit and vegetables is commonly consumed.
Material and Methods
Two hundred and one low-middle income pregnant women were recruited during their first prenatal visit. Hemoglobin, ferritin, folate and vitamin B12 levels were evaluated and a structured questionnaire was given to gather information including age, gravida, parity, frequency of pregnancy, history of abortion, and intrauterine device usage. Based on WHO and international guidelines, anemia was defined as hemoglobin <11 g/dl, and iron deficiency as ferritin <15 μg/L. Serum folate and vitamin B12 deficiencies were defined as levels below 3 ng/ml and 200 pg/ml respectively.
Results
The mean age and gestational week were 26.4±5.3 years and 9±3 weeks respectively. Mean plasma concentrations were 12.8±9.7 g/dl for hemoglobin, 22.7±17.2 μg/L for ferritin, 12.2±5.6 ng/ml for folate and 266.6±100.2 pg/ml for vitamin B12. Anemia was detected in 4.5% of pregnant women, iron deficiency in 40.3%, vitamin B12 deficiency in 29.8% and folate deficiency in 0.5% of patients. In 10.9% of patients, both vitamin B12 and iron iron deficiency was detected. There was no significant difference for age, body mass index, gravida, parity, frequency of pregnancy, history of abortion, and intrauterine device usage between women with low and normal levels of vitamin B12 and Ferritin (p>0.05).
Conclusion
Iron and vitamin B12 deficiencies were relatively common in the pregnant population consuming vegetable based diets. Iron and vitamin B12 supplementation in addition to folate must be considered for the wellbeing of the fetus in pregnant women living in areas where dietary patterns are mainly vegetable based.
doi:10.5152/jtgga.2011.36
PMCID: PMC3939272  PMID: 24591983
Hemoglobin; ferritin; folate; vitamin B12; pregnancy
13.  The Prognostic Value of Anemia in Patients with Diastolic Heart Failure 
Texas Heart Institute Journal  2009;36(3):220-225.
Anemia is prevalent in heart-failure patients, and it has been associated with increased mortality rates. In a retrospective study, we evaluated the effects of anemia on long-term survival in patients who experienced purely diastolic heart failure.
Heart-failure patients with preserved systolic function (left ventricular ejection fraction, ≥0.50) were evaluated retrospectively. Of 294 patients, 162 had anemia (group 1) and 132 had no anemia (group 2) upon baseline examination. Anemia was defined as a hemoglobin level below 12 g/dL in women and below 13 g/dL in men. Multivariate Cox proportional hazards regression was conducted in order to test whether hemoglobin levels were an independent predictor of 5-year hospitalization and mortality rates in patients with diastolic heart failure. A P value less than 0.05 was considered statistically significant.
Group 1 patients had a shorter mean survival time (37.8 ± 1.8 vs 44.9 ± 1.8 mo, P = 0.01); however, there was no significant difference between the groups in hospitalization rate (7.2 ± 7.1 vs 7.5 ± 6.3, P = 0.677). In a subgroup analysis, anemia was a significant predictor of higher mortality rates in elderly patients (age, >75 yr) who had diastolic heart failure (P = 0.018).
We found that anemia is associated with increased long-term mortality rates in patients who have diastolic heart failure. In addition, anemia appears to be an independent predictor of worse outcomes in elderly heart-failure patients.
PMCID: PMC2696500  PMID: 19568391
Age factors; anemia/blood/complications/epidemiology/mortality; diastole; heart failure/blood/complications/mortality/physiopathology; hemoglobins/analysis; patient readmission; prevalence; risk assessment; survival analysis; ventricular function/left
14.  Malaria, Intestinal Helminths and Other Risk Factors for Stillbirth in Ghana 
Objective. The objective of the study was to assess Plasmodium/intestinal helminth infection in pregnancy and other risk factors for stillbirth in Ghana. Methods. A cross-sectional study of women presenting for delivery in two hospitals was conducted during November-December 2006. Data collected included sociodemographic information, medical and obstetric histories, and anthropometric measures. Laboratory investigations for the presence of Plasmodium falciparum and intestinal helminths, and tests for hemoglobin levels were also performed. Results. The stillbirth rate was relatively high in this population (5%). Most of the stillbirths were fresh and 24% were macerated. When compared to women with no malaria, women with malaria had increased risk of stillbirth (OR = 1.9, 95% CI = 1.2–9.3). Other factors associated with stillbirth were severe anemia, low serum folate concentration, past induced abortion, and history of stillbirth. Conclusion. The fact that most of the stillbirths were fresh suggests that higher quality intrapartum care could reduce stillbirth rates.
doi:10.1155/2010/350763
PMCID: PMC2850132  PMID: 20379355
15.  Hematological parameters and prevalence of anemia among free-living elderly in south Brazil 
Objective
The aims of this study were to analyze the hematological parameters, the prevalence of anemia and the association between anemia and socioeconomic conditions in an elderly community-based population.
Methods
A population-based study was performed as part of the Multidimensional Study of the Elderly in Porto Alegre, Brazil (EMIPOA). An initial total of 1058 community residents aged 60 years and older were interviewed. Of these, 392 agreed to have a physical evaluation and a blood sample was taken from each. The hematological parameters analyzed in the blood samples included the hemoglobin concentration, mean cell volume (MCV), mean corpuscular hemoglobin concentration (MCHC) and red cell distribution width (RDW). The association between the variables and the diagnosis of anemia was assessed using the chi-squared test and a multiple logistic regression model.
Results
The overall prevalence of anemia was 12.8%. Anemia was present in 13.7% of women and in 10.4% of men. Normocytic normochromic anemia without anisocytosis was the most common type of anemia (46%). The assessment of erythrocyte morphology showed significant differences between anemic and non-anemic individuals (microcytosis = 12% vs. 1.5%, hypochromia = 40% vs. 8.8%, and anisocytosis = 26% vs. 7%). In the analysis of socioeconomic conditions, significant differences were found in respect to age and race.
Conclusion
The prevalence of anemia increases with age and is associated with race, microcytosis, hypochromia and anisocytosis. Anemia is not a condition that should be associated only with the aging process, as it may be due to pathological conditions that occur most frequently in this age group. As a result, a diagnosis of anemia warrants adequate clinical attention.
doi:10.5581/1516-8484.20130032
PMCID: PMC3672121  PMID: 23741189
Anemia; Hematology; Erythrocyte indices; Socioeconomic factors; Aging; Humans; Aged; Brazil
16.  Plasma 25-Hydroxyvitamin D Is Independently Associated with Hemoglobin Concentration in Male Subjects with Type 2 Diabetes Mellitus 
Introduction. It was reported that 25-hydroxyvitamin D level was independently associated with anemia in chronic kidney diseases, but the relation between vitamin D and anemia in diabetes mellitus is not still certain. We analyzed the relation between plasma 25-hydroxyvitamin D level and hemoglobin concentration. Materials and Methods. A cross-sectional study in male patients with type 2 diabetes was performed. Correlation coefficients and standardized partial regression coefficient for the hemoglobin concentration were evaluated. Results. Hemoglobin concentration was positively correlated with body mass index, HbA1c, estimated glomerular filtration rate, cholinesterase, and 25-hydroxyvitamin D level and negatively correlated with age, duration of diabetes mellitus, serum creatinine, and urinary albumin creatinine ratio. Multiple regression analysis revealed the independent relation of 25-hydroxyvitamin D to hemoglobin concentration. Conclusions. Plasma circulating form of vitamin D is significantly associated with hemoglobin concentration in diabetes mellitus independent of the clinical markers for kidney function or nutrition.
doi:10.1155/2011/362981
PMCID: PMC3132598  PMID: 21754928
17.  Predictors and patterns of red blood cell transfusion use among newly diagnosed cancer patients with chemotherapy-associated anemia in Western Denmark (1998–2003) 
Clinical Epidemiology  2011;3:91-99.
Objective:
Cancer patients receiving chemotherapy are at increased risk of anemia. We conducted a population-based historical cohort study in newly diagnosed cancer patients with chemotherapy-associated anemia in order to characterize red blood cell transfusion (RBCT) use.
Design:
This study evaluated cancer patients diagnosed between January 1, 1998 and December 31, 2003 using Danish National Patient Registry data. Patients were receiving chemotherapy and had a hemoglobin level ≤10.9 g/dL during the 4 months following cancer diagnosis. We characterized patterns of RBCT use and inpatient and outpatient hospitalization for transfusion. Adjusted Poisson regression models were used to evaluate the likelihood of RBCT, estimated by relative risk (RR), based on demographic and clinical factors.
Results:
Women constituted 58% of 1782 patients studied; the median age was 58 years. Two-thirds (67%) had solid tumors; 67% had stage III or IV disease at diagnosis. Overall, 713 (40%) patients received an RBCT within 120 days of cancer diagnosis, of which 94% were administered in the inpatient setting; 84% of these patients required subsequent transfusions. The median (Q1, Q3) pretransfusion hemoglobin level was 9.0 (8.4, 9.8) g/dL. Patients aged <20 years were more likely to receive an RBCT than older patients (RR 1.89; 95% confidence interval [CI] 1.44–2.49). Compared with stage IV disease, those with stage II or III disease had a lower likelihood of RBCT (stage II: RR 0.52, 95% CI: 0.37–0.72; stage III: RR 0.68, 95% CI: 0.55–0.83). Patients diagnosed with breast cancer were less likely to receive an RBCT than patients with hematologic cancers (RR 0.34, 95% CI: 0.21–0.55).
Conclusion:
In this study, 40% of cancer patients with chemotherapy-associated anemia in Western Denmark received an RBCT, usually in the inpatient setting; of these, most required subsequent transfusions. Younger age increased the likelihood of receiving an RBCT, and earlier stage or breast cancer decreased RBCT likelihood.
doi:10.2147/CLEP.S17146
PMCID: PMC3072151  PMID: 21487448
red blood cell transfusions; epidemiology; anemia
18.  Serum ferritin concentration in gestational diabetes mellitus and risk of subsequent development of early postpartum diabetes mellitus 
Purpose
To compare the serum ferritin concentrations of normal pregnant women with those having gestational diabetes mellitus (GDM) and to determine the possible role of ferritin in predicting pregnancy outcome and early development of postpartum glucose intolerance and diabetes mellitus.
Method
This case-control study consisted of 128 pregnant women (64 women with GDM and 64 age-matched healthy pregnant women) seen at a university hospital in Zanjan, Iran. Anthropometric measurements were determined, and serum ferritin, C-reactive protein, insulin, glycosylated hemoglobin (HbA1c), and hemoglobin levels were measured. Pregnancy outcomes were recorded in all subjects. In the women with GDM, a diagnostic oral glucose tolerance test was performed eight weeks after delivery.
Results
Women with GDM had a higher concentration of serum ferritin (112 ± 28.4 pmol/L in GDM versus 65 ± 16.9 pmol/L in controls, P < 0.001). A positive correlation was found between serum ferritin level and mid-pregnancy fasting plasma glucose and HbAlc levels. Although women in the highest quartile of serum ferritin had a greater than two-fold increased risk of GDM, no significant correlation was found between ferritin levels and early postpartum oral glucose tolerance test results.
Conclusions
Elevated serum ferritin concentrations in mid-pregnancy are associated with an increased risk of GDM independent of C-reactive protein and body mass index. Ferritin levels in GDM cannot be used as an indicator to predict subsequent glucose concentration in early postpartum oral glucose tolerance test.
doi:10.2147/DMSOTT.S15049
PMCID: PMC3047976  PMID: 21437111
gestational diabetes mellitus; ferritin; pregnancy outcome; diabetes mellitus; C-reactive protein
19.  Changes in hematologic indices in caucasian and non-caucasian pregnant women in the United States 
The Korean Journal of Hematology  2012;47(2):136-141.
Background
The objective of this study was to determine if there are differences in common red blood cell (RBC) indices and platelet concentrations during pregnancy and to establish if any observed differences in these parameters were based on the patient's ethnicity.
Methods
From an electronic perinatal database which stores laboratory and clinical information on a large number of births at a regional hospital specializing in obstetrical care, RBC index and platelet concentration data were retrospectively analyzed at various time points throughout pregnancy. RBC index data was collected from 8,277 pregnant women (5,802 Caucasian pregnant women and 2,475 non-Caucasian pregnant women). Platelet concentration data was available from 8252 pregnant women (5,784 Caucasian pregnant women and 2,468 non-Caucasian pregnant women).
Results
Hemoglobin (HGB) levels were significantly higher amongst Caucasian women compared to non-Caucasian women (P at least <0.01) starting at 27 weeks gestation and proceeding until term. There was no significant difference in the mean PLT counts between Caucasian and non-Caucasian pregnant women at any point during gestation.
Conclusion
There are ethnic differences in HGB levels, but not the platelet concentrations, during pregnancy. Based on this finding it would be reasonable to conduct formal prospective studies to determine the clinical significance of this difference and to establish the threshold for diagnosing gestational anemia, especially in pregnant non-Caucasian women.
doi:10.5045/kjh.2012.47.2.136
PMCID: PMC3389063  PMID: 22783361
Anemia; Complete blood count; Hemoglobin; Pregnancy; Reference Ranges
20.  Lipid-soluble vitamins A, D, and E in HIV-infected pregnant women in Tanzania 
Background/Objectives
There is limited published research examining lipid-soluble vitamins in human immunodeficiency virus (HIV)-infected pregnant women, particularly in resource-limited settings.
Subjects/Methods
This is an observational analysis of 1078 HIV-infected pregnant women enrolled in a trial of vitamin supplementation in Tanzania. Baseline data on sociodemographic and anthropometric characteristics, clinical signs and symptoms, and laboratory parameters were used to identify correlates of low plasma vitamin A (<0.7 μmol/l), vitamin D (<80 nmol/l) and vitamin E (<9.7 μmol/l) status. Binomial regression was used to estimate risk ratios and 95% confidence intervals.
Results
Approximately 35, 39 and 51% of the women had low levels of vitamins A, D and E, respectively. Severe anemia (hemoglobin <85 g/l; P<0.01), plasma vitamin E (P=0.02), selenium (P=0.01) and vitamin D (P=0.02) concentrations were significant correlates of low vitamin A status in multivariate models. Erythrocyte Sedimentation Rate (ESR) was independently related to low vitamin A status in a nonlinear manner (P=0.01). The correlates of low vitamin D status were CD8 cell count (P=0.01), high ESR (ESR >81 mm/h; P<0.01), gestational age at enrollment (nonlinear; P=0.03) and plasma vitamins A (P=0.02) and E (P=0.01). For low vitamin E status, the correlates were money spent on food per household per day (P<0.01), plasma vitamin A concentration (nonlinear; P<0.01) and a gestational age <16 weeks at enrollment (P<0.01).
Conclusions
Low concentrations of lipid-soluble vitamins are widely prevalent among HIV-infected women in Tanzania and are correlated with other nutritional insufficiencies. Identifying HIV-infected persons at greater risk of poor nutritional status and infections may help inform design and implementation of appropriate interventions.
doi:10.1038/ejcn.2010.76
PMCID: PMC3078753  PMID: 20517330
HIV; AIDS; pregnancy; Africa; vitamins
21.  Prevalence and severity of anemia among school children in Jimma Town, Southwest Ethiopia 
BMC Hematology  2014;14:3.
Background
Anemia is a major health problem worldwide. Because of health and socioeconomic problems, the prevalence of anemia is higher in developing countries. Children and pregnant women are the most vulnerable groups to anemia. The aim of the present study was to determine the magnitude of anemia among school children.
Methods
A cross-sectional household survey was conducted in January 2011 on 423 children, aged 6–14 years, selected through systematic random sampling method. Sociodemographic and anthropometric data were collected using a pre-tested questionnaire. Capillary blood was taken from the fingertip of each child and hemoglobin was measured using HaemoCue digital photometer. All the necessary safety measures were taken during blood collection. Anthropometric indicators were measured using WHO’s guideline. Data analysis was made using SPSS Version 16.0 for Windows. The association between predictors and outcome variables were measured by a stepwise logistic regression model. Ethical permission was obtained; consent of the parents/guardian was taken and confidentiality was maintained.
Result
A total of 404 children were studied. The mean age was 10.21(SD ± 1.89) years. The proportion of females was 217(53.7%). The mean hemoglobin level for both sexes was 11.59(SD ± 1.97 g/dl). The current prevalence of anemia was 152(37.6%), out of which, 73(18.1%) had mild while 79(19.6%) of them had moderate anemia. The prevalence of anemia among the age group of 6–11 years was 118(40.5%) while the prevalence among the group of 12–14 years old children was 34(30.1%). Among the selected variables in the logistic regression analysis, low family income [OR = 4.925, 95% CI(1.063,22.820)], mothers’ education [OR = 4.621, 95% CI(1.383,15.439)], intake of plant food [OR = 3.847, 95% CI(2.068, 7.157)] and intake of animal food [OR = 2.37, 95% CI(1.040,5.402)] were significantly and independently associated with anemia.
Conclusion
Anemia is a moderate public health problem in the study area. Family income, educational status of parents and inadequate plant and animal food intake are the predictors of anemia. Improving the economic status of the family, women education and health education about balanced animal and plant food consumption are recommended strategies to reduce the burden of anemia.
doi:10.1186/2052-1839-14-3
PMCID: PMC3896819  PMID: 24433408
Hemoglobin; Anemia; School children; Prevalence
22.  Association between vitamin D insufficiency and adverse pregnancy outcome: global comparisons 
Background
Vitamin D insufficiency has been associated with a number of adverse pregnancy outcomes, and has been recognized as a public health concern.
Aim
The objective of this study was to determine the impact of vitamin D deficiency on maternal complications like gestational diabetes mellitus (GDM), anemia, iron deficiency, and preeclampsia among pregnant women.
Subjects and methods
This was a cohort study undertaken at antenatal clinics at the Women’s Hospital of Hamad Medical Corporation in Doha. A total of 2,487 Arab pregnant women above 24 weeks’ gestation with any maternal complication were approached, and 1,873 women (75.3%) consented to participate in the study. Data on sociodemographic and clinical characteristics by interview and biochemistry parameters were retrieved from medical records. Multivariate logistic regression analysis was performed to determine the associated risk factors.
Results
Of the studied pregnant women, nearly half of them had vitamin D deficiency (48.4%). Younger women below 30 years old (43.2%, P = 0.032), housewives (65.3%, P = 0.008), and those on low monthly household incomes (QR5,000–9,999) (49.2%, P = 0.03) were significantly more likely to have lower vitamin D compared with those who had sufficient vitamin D levels. Exposure to sunlight (63.4%, P = 0.05), daily physical activity (64.4%, P = 0.05), and vitamin D supplement intake (89.7%, P < 0.001) were significantly lower in deficient pregnant women. In the study sample of pregnant women, 13.9% had GDM, 11.5% had anemia, 8.6% had iron deficiency, and 6.9% had preeclampsia. Severe vitamin D deficiency was significantly higher in pregnant women with GDM (16.5% vs 11%), anemia (17.1% vs 11%), iron deficiency (18.5% vs 11.2%), and preeclampsia (19.8% vs 11.4%) when compared to the uncomplicated group. Socioeconomic status was low in pregnant women with complications like GDM, anemia, iron deficiency, and pre-eclampsia. Pregnancy complications like GDM (52.7%), anemia (53.2%), iron deficiency (55.6%), and preeclampsia (51.9%) were higher in Qataris. Also, GDM (66.2%), anemia (66.2%), iron deficiency (68.5%), and preeclampsia (58.1%) were observed more commonly among housewives compared to working women. Obesity was significantly more common in pregnant women with GDM (41.5%) and preeclampsia (41.1%).
Conclusion
The study findings revealed that maternal vitamin D deficiency in pregnancy is significantly associated with elevated risk for GDM, anemia, and preeclampsia. The risk of vitamin D deficiency was higher in Qataris, housewives and those with low monthly household income.
doi:10.2147/IJWH.S51403
PMCID: PMC3772690  PMID: 24043954
pregnant women; vitamin D deficiency; GDM; anemia; iron deficiency; preeclampsia
23.  Low Serum Selenium Is Associated with Anemia Among Older Women Living in the Community: The Women’s Health and Aging Studies I and II 
Biological trace element research  2006;112(2):97-107.
Anemia is common among older adults, and a substantial proportion of anemia in the older population is of indeterminate cause. Low selenium levels have been associated with anemia in animals, but this relationship has not been well characterized in humans. The objective was to determine whether low serum selenium concentrations are associated with anemia among older women. We conducted a cross-sectional analysis of participants in the Women’s Health and Aging Studies, a population-based sample of women living in the community in Baltimore, MD, USA. Of 632 women, aged 70–79 yr, 14.1% of women were anemic (hemoglobin <120 g/L). The prevalence of anemia among women in the lowest to highest quartile of serum selenium was 22.4%, 14.6%, 11.9% and 6.6%, respectively (p < 0.0001). An increase in loge selenium was associated with a reduced risk of anemia (odds ratio per 1 SD increase = 0.63, 95% confidence interval = 0.47–0.84), adjusting for age, education, chronic diseases, iron status, and serum interleukin-6. We conclude that low serum selenium is independently associated with anemia among older women living in the community.
doi:10.1385/BTER:112:2:97
PMCID: PMC2653257  PMID: 17028376
Aging; anemia; hemoglobin; selenium; women
24.  Effects of Deworming during Pregnancy on Maternal and Perinatal Outcomes in Entebbe, Uganda: A Randomized Controlled Trial 
Background
Helminth infections during pregnancy may be associated with adverse outcomes, including maternal anemia, low birth weight, and perinatal mortality. Deworming during pregnancy has therefore been strongly advocated, but its benefits have not been rigorously evaluated.
Methods
In Entebbe, Uganda, 2507 pregnant women were recruited to a randomized, double-blind, placebo-controlled trial investigating albendazole and praziquantel in a 2 × 2 factorial design [ISRCTN32849447]. Hematinics and sulphadoxine-pyrimethamine for presumptive treatment of malaria were provided routinely. Maternal and perinatal outcomes were recorded. Analyses were by intention to treat.
Results
At enrollment, 68% of women had helminths, 45% had hookworm, 18% had Schistosoma mansoni infection; 40% were anemic (hemoglobin level, <11.2 g/dL). At delivery, 35% were anaemic; there was no overall effect of albendazole (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.79–1.15) or praziquantel (OR, 1.00; 95% CI, 0.83–1.21) on maternal anemia, but there was a suggestion of benefit of albendazole among women with moderate to heavy hookworm (OR, 0.45; 95% CI, 0.21–0.98; P = .15 for interaction). There was no effect of either anthelminthic treatment on mean birth weight (difference in mean associated with albendazole: −0.00 kg; 95% CI, −0.05 to 0.04 kg; difference in mean associated with praziquantel: −0.01 kg; 95% CI, −0.05 to 0.04 kg) or on proportion of low birth weight. Anthelminthic use during pregnancy showed no effect on perinatal mortality or congenital anomalies.
Conclusions
In our study area, where helminth prevalence was high but infection intensity was low, there was no overall effect of anthelminthic use during pregnancy on maternal anemia, birth weight, perinatal mortality, or congenital anomalies. The possible benefit of albendazole against anemia in pregnant women with heavy hookworm infection warrants further investigation.
doi:10.1086/649924
PMCID: PMC2857962  PMID: 20067426
25.  Diet-induced iron deficiency anemia and pregnancy outcome in rhesus monkeys12 
Background
Iron deficiency anemia (IDA) is relatively common in the third trimester of pregnancy, but causal associations with low birth weight and compromised neonatal iron status are difficult to establish in human populations.
Objective
The objective was to determine the effects of diet-induced IDA on intrauterine growth and neonatal iron status in an appropriate animal model for third-trimester IDA in women.
Design
Hematologic and iron-status measures, pregnancy outcomes, and fetal and neonatal evaluations were compared between pregnant rhesus monkeys (n = 14) fed a diet containing 10 μg Fe/g diet from the time of pregnancy detection (gestation days 28–30) and controls (n = 24) fed 100 μg Fe/g diet.
Results
By the third trimester, 79% of the iron-deprived dams and 29% of the control monkeys had a hemoglobin concentration <11 g/dL. There were also significant group differences in hematocrit, mean corpuscular volume, transferrin saturation, serum ferritin, and serum iron. At birth, the newborns of monkeys iron-deprived during pregnancy had significantly lower hemoglobin, mean corpuscular volume, and mean corpuscular hemoglobin values and a lower ratio of erythroid to total colony-forming units in bone marrow than did the control newborns. Pregnancy weight gain did not differ significantly between the iron-deprived and control dams, and the fetuses and newborns of the iron-deprived dams were not growth retarded relative to the controls. Gestation length, the number of stillbirths, and neonatal neurobehavioral test scores did not differ significantly by diet group.
Conclusion
These data indicate that an inadequate intake of iron from the diet during pregnancy in rhesus monkeys can lead to compromised hematologic status of the neonate without indications of growth retardation or impaired neurologic function at birth.
PMCID: PMC1538981  PMID: 16522913
Iron deficiency; pregnancy; rhesus monkeys; intrauterine growth retardation; anemia

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