Ferrodeficiency and pregnancy: what to do and when to begin?

In September 2021, an online webinar took place on the most common nutritional deficiency in the world – iron deficiency. According to the WHO recommendations, women should definitely receive iron and folic acid, starting with the stage of pregravid preparation, during pregnancy and lactation. Other trace elements and vitamins during pregnancy must be substantiated by evidence of their deficiency. WHO recommendations (2017) for antenatal care indicate that daily oral iron supplementation 30–60 mg and folic acid 400 µg in pregnant women can reduce the incidence of postpartum sepsis, preterm birth and low birth weight. Daily iron supplementation 60 mg should be preferred in regions where the prevalence of anemia in pregnant women ≥ 40%. In the first and third trimesters anemia is diagnosed by Hb level < 110 g/l, in the second trimester by Hb level < 105 g/l. If anemia is detected the iron dose is doubled until Hb reaches ≥ 110 g/l, after which the prophylactic dose is resumed. Iron supplements 120 mg once a week and folic acid 2800 µg once a week are recommended if daily intake of iron supplements is not possible due to side effects, and the prevalence of anemia in pregnant women does not exceed 20%.Modern Lipofer® technology in the development of liposomal iron delivery (when iron transported by liposomes) solved the problem of low bioavailability and poor tolerance, which is inherent in most ferrum drugs. As a result, iron trapped in liposomes (liposomal iron) does not come into contact with the mucous membranes of the gastrointestinal tract, but binds to chylomicrons, which enter the blood through the lymph, where iron is freed from the liposome. This way of absorption reduces iron loss, allows using of smaller doses and helps to avoid side effects.

Needleless Ablation of Osteoid Osteoma and Osteoblastoma: The Emergent Role of MRgFUS

Osteoblastoma (OB) and osteoid osteoma (OO) are benign bone-forming tumors, with nearly identical basic microscopic features. The main difference is dimension (OO has usually a nidus measuring <2 cm in diameter). In addition, OB is biologically more active than OO, with a tendency to grow in size. Historically, treatments have included surgical resection and analgesics, although invasiveness and poor tolerance have led to the current standard of care moving toward interventional radiology, where radiofrequency ablation (RFA) represents the most diffuse technique. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) has recently emerged as another innovative alternative treatment, providing tumor ablation through a needleless and ionizing radiation-free modality. In addition, this technique has the ability to guarantee a very precise and controlled increase in temperature, delivering small amounts of energy that can accurately destroy only the lesion, avoiding healthy surrounding tissues. The present review focuses on MRgFUS as the less invasive, safe, effective, and durable treatment option for the management of osteoid osteoma and osteoblastoma, including a description of technical details, indications and outcomes.

515 Exertional syncope and ventricular arrhythmia in a patient with cardiac amyloidosis

Aims Systemic amyloidosis is a multisystem disorder caused by the misfolding, aggregation, and deposition of certain proteins in various organs and tissues. Cardiac involvement is common and worsens the prognosis. Atrial fibrillation is the most frequent arrhythmia in cardiac amiloidosis (CA), but many cases of ventricular arrhythmias (VA) and sudden cardiac death (SCD) have been described. Methods and results We present a case of a 64-year-old man admitted following exertional syncope occurred after climbing a flight of stairs. In the previous 2 weeks he had experienced fatigue and poor tolerance to exertion; moreover, 2 days before he had another episode of transient loss of consciousness after exertion. His medical history included left gonarthrosis and surgery for right carpal tunnel syndrome one year before. Physical examination did not revealed signs of heart failure. A 12-lead electrocardiogram (ECG) showed a pseudoinfarction pattern with QS waves in V2 and V3 leads and low voltage in all limb leads (Figure 1). Routine blood tests revealed N-terminal pro-bran natriuretic peptide (NT-ProBNP) of 3436 pg/ml (n.v. 0–125) and high-sensitive troponin T of 67 pg/ml (n.v. &lt; 58). A trans-thoracic echocardiogram showed left ventricle (LV) concentric thickening wall with granular and sparkling pattern, mild reduced ejection fraction, reduced global longitudinal strain with apical sparing, grade 3 diastolic disfunction, biatrial enlargement, mild mitral regurgitation, right ventricle free wall thickening (8 mm), mild reduced TAPSE, and mild pericardial effusion. Cardiac magnetic resonance (CMR) confirmed ventricular wall thickening with evidence at T1 mapping of interstitial infiltration more evident in the septum and inferior-lateral wall with apical savings (Figure 2). A total body 99mTc-HDP scintigraphy showed cardiac uptake with intensity similar to bone signal (Perugini Score 2) suggesting ATTR cardiac amyloidosis (Figure 3). Both kappa and lambda concentrations were normal. The genetic testing did not reveled mutations in the TTR gene. We concluded for a diagnosis of ATTR wild-type CA. The Holter ECG monitoring registered numerous ventricular ectopic beats and an episode of non-sustained ventricular tachycardia. A coronary angiography ruled out coronary artery disease. In consideration of the clinical-instrumental picture an ICD was implanted. Conclusions In conclusion, CA is still underdiagnosed. VA and SCD may further complicate the prognosis. Early diagnosis and adequate stratification of the arrhythmic risk are essential to ensure patients the best therapeutic strategies.

Diffuse Pain and Abnormal Brain MRI Findings

A 46-year-old woman with a remote history of classical migraine had development of pain behind her left eye followed by holocephalic headache. She subsequently began to have episodic headaches. Her sleep became disrupted. Irritability, cognitive symptoms, and fatigue then developed. Her headaches occurred daily, along with whole-body discomfort. She underwent polysomnography and was diagnosed with obstructive sleep apnea syndrome. Her sleep quality improved with continuous positive airway pressure therapy, but her daily headaches, cognitive symptoms, and limb pain persisted. She was diagnosed with “seronegative Lyme disease.” Fourteen days of doxycycline therapy was not accompanied by improvement in symptoms. After extensive laboratory evaluations and consultations, the patient was diagnosed with fibromyalgia. Short trials of low doses of amitriptyline, nortriptyline, gabapentin, and pregabalin were undertaken, but these were poorly tolerated and discontinued in each instance. The patient was concerned that she may have multiple sclerosis, and she underwent magnetic resonance imaging of the brain. The radiology report documented multiple, small areas of T2-signal change, and demyelinating disease was included in the radiologic differential diagnosis. The patient then sought a second opinion. Evaluations at Mayo Clinic supported evidence of diffuse myofascial limb and back pain and tenderness. Brain magnetic resonance images were reviewed. Extensive work-up for alternative differential diagnostic considerations for her pain was unremarkable. The patient was diagnosed with fibromyalgia with features of central sensitization, with brain magnetic resonance imaging demonstrating nonspecific radiologic abnormalities. A detailed discussion about fibromyalgia and central sensitization was undertaken with the patient. The concepts rehabilitative approaches were reviewed. Slowly progressive, incremental, physical reconditioning, and cognitive behavioral retraining were recommended. She was advised to complete a fibromyalgia and chronic fatigue treatment program, focusing on cognitive and behavioral approaches, stress management, sleep hygiene, balanced lifestyle, moderation, energy conservation, and graded exercise. No new medications were recommended given her previous poor tolerance. The patient’s atypical symptoms, normal examination findings, and brain magnetic resonance imaging appearance assisted in excluding a diagnosis of demyelinating disease. The radiologic findings, termed white matter leukoaraiotic change, are commonly encountered in healthy persons as they age, particularly in patients with migraine or those with microvascular risk factors.

NAT2 and CYP1B1 genetic polymorphisms in patients with genital endometriosis depending on tolerability of melatonin

BACKGROUND: Genital endometriosis is one of the most pressing problems of modern gynecology. Melatonin is a promising drug with a potentially curative effect on endometriosis. AIM: The aim of this study was to conduct a comparative analysis of the genetic polymorphism of some genes encoding enzymes involved in melatonin metabolism. MATERIALS AND METHODS: The genetic polymorphism in the NAT2 and CYP1B1 genes encoding enzymes involved in melatonin metabolism in patients with different tolerance to this drug was analyzed by PCR-RFLP analysis. RESULTS: In patients with genital endometriosis, the presence of a wild-type allele (N) of the NAT2 gene was associated with poor tolerance of melatonin. The NAT2 (N / N) rapid acetylator phenotype combined with the low catalytic activity of CYP1B1 (C / C) occurred more frequently in endometriosis patients having poor melatonin tolerability compared to the group of patients who tolerated the therapy well. CONCLUSIONS: For patients with genital endometriosis with the wild-type (N) allele of the NAT2 gene, melatonin administration is inappropriate due to numerous side effects during the drug use.

Use of Hypnosis in Paediatric Gastrointestinal Endoscopy: A Pilot Study

Objectives: Experience of hypnosis in gastrointestinal (GI) endoscopy is scarce in children. Our aims were to assess the rate of successful GI endoscopy performed using hypnosis alone or in combination with midazolam, with or without additional equimolar mixture of oxygen and nitrous oxide (EMONO), and to identify predictive factors of successful endoscopy in children.Methods: This prospective single-centre study included children older than 6 years requiring a diagnostic esophagogastroduodenoscopy (EGD) or rectosigmoidoscopy. Ericksonian hypnosis was performed alone or in combination with midazolam, with or without additional EMONO. Successful endoscopy was defined by a complete and well-tolerated procedure. Levels of satisfaction of the endoscopist, nurse, and patient were assessed.Results: One hundred forty children [70 boys, median age: 12 years (Q1–Q3: 9–14)] were included over a 14-month period. They underwent EGD in 51.4% (n = 72) and rectosigmoidoscopy in 48.6% (n = 68) of cases. EMONO and midazolam were combined with hypnosis in 136 cases (97.1%). Successful endoscopy rate reached 82.9%. The procedure was interrupted due to poor tolerance and was rescheduled under general anaesthesia in 11 patients (7.9%). Predictive factors for successful endoscopy were older age (13 vs. 8 years, OR: 1.34, CI 95% [1.10–1.62], p = 0.003) and type of endoscopy (EGD vs. rectosigmoidoscopy, OR: 16.34 [2.14–124.68], p = 0.007). A good cooperation of the patient was reported by the endoscopist and the nurse in 88.4 and 86.9% of cases, respectively. Ninety-two per cent of patients mentioned that the procedure went well.Conclusions: Our study suggests that hypnosis combined with EMONO and/or midazolam is of additional value to perform diagnostic EGD or rectosigmoidoscopy in children older than 6 years without systematic need for general anaesthesia.

Pervasive developmental disorders with a complex structure (epileptic seizures, catatonic, hallucinatory and manic symptoms, delirious episodes during life).

Observation of two patients with Phelan-McDermid syndrome (22q13.3 microdeletions of the SHANK3 gene) within 10—12 years allowed us to describe the clinical pathomorphism of psychotic episodes with violation of consciousness and catatonic symptoms in adolescence with autism spectrum disorders (ASD). The described phenotypes were characterized by intellectual disability, general speech underdevelopment, muscle hypotonia and developmental dyspraxia. Their causal relationships with epileptic encephalopathy, schizophrenia, bipolar and hyperkinetic disorders have been analyzed. The therapeutic efficacy of combination therapy with aripiprazole and benzodiazepines (clonazepam/diazepam) allowed qualifying psychotic episodes as pediatric delirium. The significant clinical efficacy of lithium and lamotrigine in the described patients was consistent with the hypothesis that microdeletion of the SHANK3 gene may be associated with bipolar disorder. Treatment of acute psychotic disorders with lithium salt was effective in both patients but had limitations due to poor tolerance in the long-term use. The combination of lithium and lamotrigine may be recommended for the treatment of polymorbid mental disorders in patients with SHANK3 encephalopathies. If lithium salts are poorly tolerated, a combination of lamotrigine and aripiprazole may be used.

INDICATIONS OF CAESAREAN ACCORDING TO ROBSON’S CRITERIA

Introduction: There has been an increase in rate of caesarean section over past five decades. This is matter of public health concern as it increases the caesarean section related maternal morbidity and mortality. Asadvised by WHO guidelines and US health initiative C-section rate should not beyond 15%. According to NHFS-4 C-section rate in India 17.2%. The aim of present study aimed to assess the rate of CS and perform and analysis based on Robson classification system. Methods: In present study all the cases delivered by caesarean section during period of six months were recorded. Data were collected from medical records of women who delivered from October to march 2021.They were classified according to Robsons’10 group classification system. This was an attempt to see which relevant group contributed most to the c- section rates. Results: There was a trend of increased percentage of caesarean section in group5 patients in present study. Poor tolerance to pain and increased rate of previous c section contributes to this. Conclusion: We should make use of vaginal delivery after caesarean section but not at the cost of maternal and fetal health. These target groups require more in depth analysis to identify modifiable risk factors and apply specific intervention to reduce cs rates. Keywords: Indications, Caesarean, Robsons criteria.

Effect of Complexation Conditions on Microcapsulation of Lactobacillus Casei L61 in Gellan Gum–Chitosan Gels

Probiotics have many benefits for human intestinal health. However, Probiotics have poor tolerance to gastric acid and bile salts of the stomach. Microencapsulation could confer protection to probiotic against harsh environments effectively. In this experiment, Lactobacillus casei L61 was embedded by extrusion with gellan gum and chitosan as wall material. The viable cells and encapsulation yield of microcapsules were used as the indexes, the optimum values of each factor were determined by a single factor experiment. Chitosan concentration 0.50%, chitosan pH 4.5, gellan gum concentration 1.50%, the volume ratio of bacterial suspension to gellan gum is 1:6, the volume ratio of bacterial gum to chitosan is 1:4, the stirring time is 40min.

AB0665 SWITCHING INTRAVENOUS ABATACEPT AND TOCILIZUMAB TO SUBCUTANEOUS INJECTIONS DURING THE COVID-19 PANDEMIC: A FRENCH EXPERIENCE

Background:The COVID-19 pandemic requires measures to reduce patient exposure to the risk of contamination, in particular by limiting hospital admissions and promoting lockdown. In order to respond to these healthcare measures, patients were offered to replace intravenous infusions (IV) of abatacept (ABT) and tocilizumab (TCZ) to subcutaneous injections (SC).Objectives:To assess the outcome of patients who switched from IV ABT or TCZ to SC during the COVID-19 pandemic.Methods:A survey was conducted in December 2020 in partnership with the national AFP-RIC patient association to assess the outcome and satisfaction of patients who switched from ABT or TCZ IV to SC during the first wave of COVID-19 pandemic.We also analysed the outcome of patients who switched from IV ABT or TCZ to SC in the rheumatology department of Cochin Hospital during the lockdown in April/may 2020. Articular activity parameters (swollen joint count, pain joint count, visual analogic pain scale, CRP, DAS-28 activity score) were assessed at medical visits before and 6 months after switching from IV to SC.The data collected from the AFP-RIC patient association and the rheumatology department of Cochin Hospital were then aggregated and analyzed by Chi-square and Wilcoxon tests.Results:81 patients responded to the survey carried out by AFP-RIC patient association, including 29 treated with IV ABT (n=15, 52%) or TCZ (n=14, 48%). 17/29 (59%) were offered to switch from IV to SC, 14/17 patients (82%) accepted and 7 patients were still receiving ABT or TCZ SC injections in December 2020. In the rheumatology department of Cochin hospital, 71 patients were scheduled in April/May 2020 to receive IV ABT or TCZ, and 27 (38%) switched to SC. After 6 months, 19 patients (70%) had maintained SC injections, were satisfied with this injection route of administration and their articular activity parameters were unchanged (Table 1).Table 1.Course of Disease parameters evaluated in the 19 patients who maintained abatacept or tocilizumab SC injections in the Rheumatology department of Cochin HospitalParameter, mean(SD)Inclusion visitSwitch to SC(n=19)6 month visit (n=19)P-valueDAS282.3 (1.2)2.3 (0.7)0.62Tender joint count2.5 (3.5)1.3 (1.7)0.49Swollen joint count1.3 (2.5)0.9 (0.6)0.35Patient Global Health (cm)3.2 (1.9)2.6 (1.8)0.60CRP (mg/L)3.2 (4.1)5.2 (4.9)0.56CRP: C-Reactive Protein, SD: Standard DeviationThe combined analysis of these two populations included 41 patients (33 rheumatoid arthritis, RA, 7 juvenile idiopathic arthritis, JIA and 1 polymyalgia rheumatica) who switched to SC ABT or TCZ. 26/41 (63.5%) patients maintained SC injections and IV was re-established in 15/41 (36.5%). Reasons for returning to IV were poor tolerance of SC injections (n=6, 40%), worsening symptoms (n=11, 73%), patient preference to see a rheumatologist in hospital (n=10, 67%) and the high number of SC injections (n=2, 13%). The proportion of patients returning to IV was higher in RA patients compared to patients with JIA (42% vs. 14%, p = 0.08). Age and disease duration were not significantly different between patients who maintained SC injections and those who returned to IV (respectively p=0.97 and p=0.63).Conclusion:Our study suggests that switching from IV ABT or TCZ to SC is an acceptable procedure during the COVID-19 pandemic, especially for patients with JIA.Acknowledgements:Association AFP-RIC (Angélique Hochedé, Cyrielle Beller, Sandrine Rollot) and the members of the association for their help in the conduction of the surveyDisclosure of Interests:None declared.