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Deferasirox is a once-daily, oral iron chelator developed for treating transfusional iron overload. Preclinical studies indicated that the kidney was a potential target organ of toxicity. As patients with sickle cell disease often have abnormal baseline renal function, the primary objective of this randomised, open-label, phase II trial was to evaluate the safety and tolerability of deferasirox in comparison with deferoxamine in this population. Assessment of efficacy, as measured by change in liver iron concentration (LIC) using biosusceptometry, was a secondary objective. A total of 195 adult and paediatric patients received deferasirox (n = 132) or deferoxamine (n = 63). Adverse events most commonly associated with deferasirox were mild, including transient nausea, vomiting, diarrhoea, abdominal pain and skin rash. Abnormal laboratory studies with deferasirox were occasionally associated with mild non-progressive increases in serum creatinine and reversible elevations in liver function tests. Discontinuation rates from deferasirox (11.4%) and deferoxamine (11.1%) were similar. Over 1 year, similar dose-dependent LIC reductions were observed with deferasirox and deferoxamine. Once-daily oral deferasirox has acceptable tolerability and appears to have similar efficacy to deferoxamine in reducing iron burden in transfused patients with sickle cell disease.
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PMID:A randomised comparison of deferasirox versus deferoxamine for the treatment of transfusional iron overload in sickle cell disease. 1723 48

A 4-year-old girl was evaluated for hair loss of a few weeks' duration. History of the present illness, medical history, and review of systems were obtained from the parents, who described progressive diffuse hair loss with hair dryness and brittleness, with no change in the child's eating habits or any other unusual symptoms. No fever, weight loss, diarrhea, vomiting, abdominal pain, chronic cough, dyspnea, change in appetite, change in bowel habit, or urinary symptoms were noted. On further questioning, her nutritional history revealed that she always favored cow's milk in her diet. The patient has been healthy with no significant medical history, surgical history, psychiatric history, or history of hospitalization. She was taking no medications. Her mother's pregnancy and the child's birth history were uneventful. The child was up-to-date on her vaccinations. Her physical examination showed a healthy-appearing child who was at 50% on the height chart and 70% on the weight growth chart. She was afebrile with a respiratory rate of 24 breaths per minute, pulse rate of 110 beats per minute, and pulse oximetry of 99% on room air. Skin examination revealed interstitial diffuse patchy alopecia with very dry hair and nonscarred, normal-appearing scalp. The hair pull test was normal, with 4 hairs extracted. Results of examination of her eyes (including visual acuity) and lungs were normal, and no abnormalities were found on heart, abdominal, musculoskeletal, and neurologic examinations. Laboratory workup showed normal electrolytes, blood urea nitrogen, creatinine, and blood sugar levels. Her complete blood cell count with differential was normal, ferritin concentration level was 110 ng/mL (reference, 40-200 ng/mL), iron level was 75 microg/dL (reference, 35-175 microg/dL), and total iron-binding capacity was 310 microg/dL (reference, 245-400 microg/dL). Levels of liver enzymes, total bilirubin, serum protein, and albumin were normal, as were the results of urinalysis. Thyroid function test results were normal and levels of vitamins A and D were also normal. Low levels of serum zinc were measured repeatedly at 48 and 61 microg/dL (reference, 66-144 microg/dL) at 2 different laboratories. She was started on zinc supplement (50 mg daily) for 6 months and her diet was modified. The hair loss stopped in 3 weeks. Follow-up in 4 months showed no evidence of alopecia, with normal-looking hair.
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PMID:Diffuse alopecia in a child due to dietary zinc deficiency. 1761 80

Anatomical change in the anatomy of the gastrointestinal tract after bariatric surgery leads to modification of dietary patterns that have to be adapted to new physiological conditions, either related with the volume of intakes or the characteristics of the macro- and micronutrients to be administered. Restrictive diet after bariatric surgery (basically gastric bypass and restrictive procedures) is done at several steps. The first phase after surgery consists in the administration of clear liquids for 2-3 days, followed by completely low-fat and high-protein content (> 50-60 g/day) liquid diet for 2-4 weeks, normally by means of formula-diets. Soft or grinded diet including very soft protein-rich foods, such as egg, low-calories cheese, and lean meats such as chicken, cow, pork, or fish (red meats are not so well tolerated) is recommended 2-4 weeks after hospital discharge. Normal diet may be started within 8 weeks from surgery or even later. It is important to incorporate hyperproteic foods with each meal, such egg whites, lean meats, cheese or milk. All these indications should be done under the supervision of an expert nutrition professional to always advise the patients and adapting the diet to some special situations (nausea/vomiting, constipation, diarrhea, dumping syndrome, dehydration, food intolerances, overfeeding, etc.). The most frequent vitamin and mineral deficiencies in the different types of surgeries are reviewed, with a special focus on iron, vitamin B12, calcium, and vitamin D metabolism. It should not be forgotten that the aim of obesity surgery is making the patient loose weight and thus post-surgery diet is designed to achieve that goal although without forgetting the essential role that nutritional education has on the learning of new dietary habits contributing to maintain that weight loss over time.
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PMID:[Nutritional implications of bariatric surgery on the gastrointestinal tract]. 1767

This cross-sectional survey sought to document complementary and alternative medicine (CAM) use by Texas midwives, as well as to determine whether licensed direct-entry midwives (LMs) and certified nurse-midwives (CNMs) differed significantly in their patterns of use. All respondents (n = 69) indicated that they used, recommended, or referred their clients for at least one CAM therapy during the preceding year. Ninety percent (90%) of respondents used, recommended, or referred their clients for an herbal remedy (not including homeopathic tinctures). Herbal therapies were among the top three modalities recommended for 7 of 12 (58%) clinical indications. Herbs were the most salient CAM therapy used for cervical ripening (83%), followed closely by use for nausea, vomiting, and hyperemesis (80%), and labor induction (77%). Herbal therapies also constituted 50% or more of the CAM therapies used for the following indications: anemia/iron supplementation (70%), perineal healing (66%), and anxiety/stress/fatigue (50%). LM respondents used, recommended, or referred their clients for a greater number of herbal therapies compared to CNMs. While several of the CAM modalities used or recommended by Texas midwives show potential for clinical benefit, few have been studied sufficiently to determine their efficacy or safety during pregnancy.
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PMID:Herbal and other complementary medicine use by Texas midwives. 1782 10

Patients with thalassemia major requiring regular blood transfusions accumulate iron that is toxic to the heart, liver, and endocrine systems. The following prospective, randomized trial was carried out to determine the effectiveness, in children and young adults, of combined deferiprone (DFP) and deferoxamine (DFO) in reducing transfusional iron overload compared to either drug alone and to assess the safety and tolerability of DFP. Sixty-six patients were randomized into three treatment arms: daily DFP combined with DFO twice weekly; daily DFP only; and DFO only 5 days/week. Fifty-six patients completed the 54 weeks and were assessed by different indices. A significant reduction of liver iron concentration and serum ferritin was observed in all three arms while significant reduction of liver iron score was observed in patients on combination therapy only. Cardiac function did not significantly change in any arm. Compliance improved in patients who received combined therapy. Toxicity of DFP was mild to moderate and acceptable; most commonly, transient arthropathy and nausea/vomiting were observed. Thus, combination therapy has shown to be effective in reducing iron overload in thalassemia patients.
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PMID:Iron chelation in thalassemia: combined or monotherapy? The Egyptian experience. 1835 37

Cefdinir is an extended-spectrum, third-generation cephalosporin that may be used for treatment of acute otitis media in patients allergic to penicillin. When administered with iron-containing products, including infant formulas, cefdinir or one of its metabolites may bind to ferric ions, forming a nonabsorbable complex that imparts a reddish color to the stool. We describe a 9-month-old infant with failure to thrive and acute otitis media who developed an erythematous maculopapular rash during treatment with amoxicillin-clavulanate. His antibiotic therapy was changed to cefdinir. Five days into a 10-day course of therapy, the infant's mother brought him to the pediatric clinic and reported the appearance of red stools. He had no associated gastrointestinal symptoms (vomiting, abdominal pain, or diarrhea). His hematocrit and hemoglobin level were normal, and Clostridium difficile antigen studies and tests for species of Shigella, Salmonella, and Camphylobacter as well as ova and parasites were all negative. Cefdinir was discontinued, and his stools returned to normal within 48 hours. Three weeks later, he again received cefdinir for recurrent otitis media. Red stools reappeared 48 hours later, were determined to be guaiac negative, and resolved within hours of drug discontinuation. During both occurrences of red stools, the infant had been breastfed and was receiving supplemental feedings with an iron-containing infant formula. In the product labeling of cefdinir, this adverse event is described as a consequence of the drug-drug interaction; however, it is not listed in the adverse drug reaction section of the labeling. As such, one may miss the association between cefdinir and reddish stools when investigating this event as a potential adverse reaction to cefdinir. When using the Naranjo adverse drug reaction probability scale to assess causality in our patient's case, this adverse drug reaction was determined as highly probable. As this infant had been breastfed, the use of a supplemental iron-containing infant formula was not identified as a potential contributing factor until the second occurrence of red stools. Health care professionals should review the entire product labeling, including the drug-drug interaction section, when investigating a potential adverse drug reaction. With the recent approval of generic formulations of cefdinir, clinicians should be aware of this drug-drug interaction with iron-containing products to prevent unnecessary alarm by parents and caregivers, as well as costly medical evaluations for gastrointestinal bleeding.
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PMID:Nonbloody, red stools from coadministration of cefdinir and iron-supplemented infant formulas. 1844 64

Small bowel tumors are rare, accounting for 1-2% of all gastrointestinal neoplasms. We sought to determine the diagnostic and therapeutic impact of double-balloon enteroscopy (DBE) in patients with small bowel tumors. Between January 2005 and March 2008, 78 patients underwent 96 DBE. All nine patients (seven males; mean age 68 +/- 11.3 years) with small bowel tumors were retrospectively reviewed. Clinical presentation was: mid-gastrointestinal bleeding or iron-deficient anemia (55.6%); abdominal pain (22.2%); nausea/vomiting and abdominal distension (22.2%). Five patients had abnormal findings in previous capsule endoscopy and four in previous radiologic examinations. Route of insertion was exclusively oral and abnormal lesions were detected in all patients (jejunum 8; ileum 1). Biopsies were taken in seven patients and provided definitive histological diagnosis in all except one. There were no complications of DBE. Surgical resection took place in eight patients. Final histologic diagnosis were: primary carcinoma (33.3%), gastrointestinal stromal tumor (GIST) (33.3%), malignant lymphoma (22.2%), and carcinoid tumor (11.1%). Mean follow-up time was 15.4 +/- 12.7 months (range 2-34 months). Six patients were submitted to chemotherapy. Two patients died. Small bowel tumors are common in patients submitted to DBE. Given its safety and diagnostic capabilities, DBE should be considered the gold-standard method in the study of these neoplasms.
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PMID:Double-balloon enteroscopy and small bowel tumors: a South-European single-center experience. 1895 20

Iron ingestion accounts for approximately 3% of calls to poison control centers. The profound local and systemic effects of an iron overdose have an associated mortality rate of 5%. Laparotomy and gastrotomy has been reported as a life-saving maneuver to extract the retained iron aggregates that are notoriously resistant to, removal by conventional emesis or lavage techniques. In this paper, we describe, for the first time, the use of laparoscopic-assisted gastrotomy in the treatment of an iron overdose. A 14-year-old girl attempted suicide by means of a polydrug drug overdose, which included ferrous fumarate, at a calculated potentially lethal dose of 70 mg/kg. A gastric iron bezoar was seen on plain radiograph. The regional poison control center recommended surgical removal of the retained iron tablets. Upper endoscopy confirmed the retention of iron and showed its dense adherence to the gastric mucosa. A 5-mm laparoscope was introduced at the umbilicus, and the stomach was grasped by an instrument introduced through a left-upper quadrant incision. The incision was then enlarged to allow the formation of a gastrotomy. The iron bezoar was removed with the aid of digital disimpaction and copious saline irrigation. The patient made a rapid postoperative recovery prior to undergoing psychiatric treatment. We conclude that laparoscopic-assisted gastrotomy is a simple and safe option in the acute management of a retained iron bezoar.
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PMID:Emergency laparoscopic-assisted gastrotomy for the treatment of an iron bezoar. 1897 22

The usual form of presentation of celiac disease is chronic diarrhoea and deficiencies of vitamin D, vitamin K, iron and vitamin B12, due to malabsorption. Intestinal obstruction secondary to an intussusception is rare in adults and usually is a complication of carcinoma of the colon or post-operative adhesions. We report a 45 year-old female consulting for diarrhoea and vomiting lasting one week and progressive abdominal bloating. A plain abdominal X ray showed air fluid levels in the small bowel and a CT scan showed an intussusception. She was operated and discharged but continued with diarrhoea. She was admitted again and a new CT scan showed three intussusceptions that were resolved with the administration of oral contrast media. Antiendomisial antibodies were positive and a celiac disease was diagnosed. After one year with a gluten free diet, the patient remains asymptomatic.
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PMID:[Celiac disease presenting as an intestinal intussusception. Report of one case]. 1903 Jun 64

Nausea and vomiting of pregnancy (NVP) is experienced by the majority of pregnant women, and can negatively affect a women's quality of life. It has been suggested in observational studies that iron-containing prenatal multivitamins may increase the severity of NVP. The objective of this study was to determine whether decreasing iron exposure can mitigate NVP symptoms. Data were collected from a prospective cohort at the Motherisk Program in Toronto. Women (n = 97) seeking advice on managing severe NVP were advised to discontinue prenatal multivitamin administration and switch to folic acid, an adult multivitamin or a children's chewable multivitamin. Two-thirds (63 out of 97) (p < 0.001) of those women qualitatively reported an improvement in NVP symptoms after discontinuation of iron-containing prenatal multivitamins. These findings were verified quantitatively using both the pregnancy-unique quantification of emesis and nausea (PUQE) (p < 0.001) and well-being (p < 0.001) scoring systems. This is the first interventional study showing that discontinuation of iron results in improvement of NVP symptoms. Our data suggest that avoiding iron-containing prenatal multivitamins in the first trimester is effective in improving NVP symptoms in the majority of pregnant women suffering from morning sickness.
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PMID:The effectiveness of discontinuing iron-containing prenatal multivitamins on reducing the severity of nausea and vomiting of pregnancy. 1928 Apr 88


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