{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,25]],"date-time":"2026-03-25T12:35:15Z","timestamp":1774442115012,"version":"3.50.1"},"update-to":[{"DOI":"10.12688\/amrcopenres.12963.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2021,3,22]],"date-time":"2021-03-22T00:00:00Z","timestamp":1616371200000}}],"reference-count":19,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2021,3,22]],"date-time":"2021-03-22T00:00:00Z","timestamp":1616371200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000654","name":"Marie Curie","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000654","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["amrcopenresearch.org"],"crossmark-restriction":false},"short-container-title":["AMRC Open Res"],"abstract":"<ns3:p>\n                    <ns3:bold>Background:<\/ns3:bold>\n                    Anaemia is common in hospice populations and associated with significant symptom burden. Guidelines recommend investigating for and treating iron deficiency (ID), but there is little evidence of this practice in palliative care populations. This report describes the results of investigations for and subsequent management of ID in a UK hospice.\n                  <\/ns3:p>\n                  <ns3:p>\n                    <ns3:bold>Methods:<\/ns3:bold>\n                    This is a descriptive study of routine clinical data. Laboratory and clinical records were reviewed retrospectively for 12 months following the implementation, in August 2018, of routine investigation for ID amongst patients with clinically relevant anaemia in whom treatment would be considered. Absolute (AID) and functional iron deficiency (FID) were diagnosed using established definitions and treatments recorded.\n                  <\/ns3:p>\n                  <ns3:p>\n                    <ns3:bold>Results:<\/ns3:bold>\n                    Iron status was evaluated in 112 cases, representing 25\/110 (22.7%) of those with mild, 46\/76 (60.5%) moderate and 41\/54 (75.9%) severe anaemia. Twenty-eight (25%) were defined as having AID, 48 (42.8%) FID and 36 (32%) no ID. There was a significant difference between groups in symptoms triggering haemoglobin check and diagnosis, with a higher proportion of patients with classic symptoms of anaemia and gastrointestinal malignancy in those with AID. Intravenous iron was given on 12 occasions in the hospice with no major adverse events. Subjective symptom benefit in 7 cases and a statistically significant increase in overall mean haemoglobin were observed.\n                  <\/ns3:p>\n                  <ns3:p>\n                    <ns3:bold>Conclusions:<\/ns3:bold>\n                    This report describes the outcome of investigations for iron deficiency in patients with clinically significant anaemia in a UK hospice. Results indicate iron deficiency is common and can be safely treated with intravenous iron replacement, within current guidelines, in a hospice setting. Further research should define the optimum use of this approach in palliative care patients.\n                  <\/ns3:p>","DOI":"10.12688\/amrcopenres.12963.2","type":"journal-article","created":{"date-parts":[[2021,3,22]],"date-time":"2021-03-22T11:40:06Z","timestamp":1616413206000},"page":"6","update-policy":"https:\/\/doi.org\/10.12688\/amrcopenres.crossmark-policy","source":"Crossref","is-referenced-by-count":2,"title":["Investigation and management of iron deficiency anaemia in a specialist palliative care setting and the role of intravenous iron: a descriptive analysis of hospice data"],"prefix":"10.12688","volume":"3","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9930-7843","authenticated-orcid":false,"given":"Thomas","family":"Steele","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Helen","family":"Bonwick","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0014-3741","authenticated-orcid":false,"given":"Amara Callistus","family":"Nwosu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Laura","family":"Chapman","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2560","published-online":{"date-parts":[[2021,3,22]]},"reference":[{"key":"ref-1","doi-asserted-by":"publisher","first-page":"1132-39","DOI":"10.1016\/j.jpainsymman.2003.04.001","article-title":"Anemia at the End of Life: Prevalence, Significance, and Causes in Patients Receiving Palliative Care.","volume":"26","author":"A Dunn","year":"2003","journal-title":"J Pain Symp Manag."},{"key":"ref-2","doi-asserted-by":"publisher","first-page":"CD009007","DOI":"10.1002\/14651858.CD009007.pub2","article-title":"Blood transfusions for anaemia in patients with advanced cancer.","volume":"2012","author":"N Preston","year":"2012","journal-title":"Cochrane Database Syst Rev."},{"key":"ref-3","doi-asserted-by":"publisher","first-page":"233-241","DOI":"10.1111\/trf.14413","article-title":"Red blood cell transfusion in adult palliative care: a systematic review.","volume":"58","author":"N Chin-Yee","year":"2018","journal-title":"Transfusion."},{"key":"ref-4","doi-asserted-by":"publisher","first-page":"102-108","DOI":"10.1177\/0269216318801755","article-title":"National comparative audit of red blood cell transfusion practice in hospices: Recommendations for palliative care practice.","volume":"33","author":"K Neoh","year":"2019","journal-title":"Palliat Med."},{"key":"ref-5","doi-asserted-by":"publisher","first-page":"1243-1249","DOI":"10.1038\/sj.bjc.6600247","article-title":"The level of haemoglobin in anaemic cancer patients correlates positively with quality of life.","volume":"86","author":"M Lind","year":"2002","journal-title":"Br J Cancer."},{"key":"ref-6","doi-asserted-by":"publisher","first-page":"1909-1917","DOI":"10.1002\/cncr.22221","article-title":"Quality-of-Life and Health Benefits of Early Treatment of Mild Anemia: a randomized trial of epoetin alfa in patients receiving chemotherapy for hematologic malignancies.","volume":"107","author":"D Straus","year":"2006","journal-title":"Cancer."},{"key":"ref-7","doi-asserted-by":"publisher","first-page":"1886-1892","DOI":"10.1093\/annonc\/mdt118","article-title":"Prevalence of iron deficiency across different tumors and its association with poor performance status, disease status and anemia.","volume":"24","author":"H Ludwig","year":"2013","journal-title":"Ann Oncol."},{"key":"ref-8","doi-asserted-by":"publisher","first-page":"907-919","DOI":"10.1007\/s00508-015-0842-3","article-title":"Iron metabolism and iron supplementation in cancer patients.","volume":"127","author":"H Ludwig","year":"2015","journal-title":"Wien Klin Wochenschr."},{"key":"ref-9","doi-asserted-by":"publisher","first-page":"iv96-iv110","DOI":"10.1093\/annonc\/mdx758","article-title":"Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines.","volume":"29","author":"M Aapro","year":"2018","journal-title":"Ann Oncol."},{"key":"ref-10","doi-asserted-by":"publisher","first-page":"1309-1316","DOI":"10.1136\/gut.2010.228874","article-title":"Guidelines for the management of iron deficiency anaemia.","volume":"60","author":"A Goddard","year":"2011","journal-title":"Gut."},{"key":"ref-11","doi-asserted-by":"publisher","first-page":"639-648","DOI":"10.1111\/bjh.12311","article-title":"Guideline for the laboratory diagnosis of functional iron deficiency.","volume":"161","author":"D Thomas","year":"2013","journal-title":"Br J Haematol."},{"key":"ref-12","doi-asserted-by":"publisher","first-page":"1695-1700","DOI":"10.1007\/s13277-012-0426-z","article-title":"Ferritin as an Independent Mortality Predictor in Patients With Pancreas Cancer. Results of a Pilot Study.","volume":"33","author":"M Kalousov\u00e1","year":"2012","journal-title":"Tumour Biol."},{"key":"ref-13","doi-asserted-by":"publisher","first-page":"1717-1725","DOI":"10.7150\/jca.26853","article-title":"Prognostic Value of Ferritin-to-Hemoglobin Ratio in Patients with Advanced Non-Small-Cell Lung Cancer.","volume":"10","author":"S Lee","year":"2019","journal-title":"J Cancer."},{"key":"ref-14","doi-asserted-by":"publisher","first-page":"1954-1962","DOI":"10.1093\/annonc\/mds112","article-title":"Prevalence and management of cancer-related anaemia, iron deficiency and the specific role of i.v. iron.","volume":"23","author":"M Aapro","year":"2012","journal-title":"Ann Oncol."},{"key":"ref-15","doi-asserted-by":"publisher","first-page":"345","DOI":"10.1186\/s12882-017-0688-1","article-title":"Renal association clinical practice guideline on Anaemia of Chronic Kidney Disease.","volume":"18","author":"A Mikail","year":"2017","journal-title":"BMC Nephrol."},{"key":"ref-16","doi-asserted-by":"publisher","first-page":"2129-2200","DOI":"10.1093\/eurheartj\/ehw128","article-title":"2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.","volume":"37","author":"P Ponikowski","year":"2016","journal-title":"Eur Heart J."},{"key":"ref-17","doi-asserted-by":"publisher","first-page":"406-409","DOI":"10.1177\/0269216308101210","article-title":"Assessment of iron status and the role for iron-replacement therapy in anaemic cancer patients under the care of a specialist palliative care unit.","volume":"23","author":"K Robertson","year":"2009","journal-title":"Palliat Med."},{"key":"ref-18","doi-asserted-by":"publisher","first-page":"1209-1214","DOI":"10.1007\/s00520-016-3511-9","article-title":"Estimating prevalence of functional iron deficiency anaemia in advanced cancer.","volume":"25","author":"K Neoh","year":"2017","journal-title":"Support Care Cancer."},{"key":"ref-19","article-title":"Investigation and management of iron deficiency anaemia in a specialist palliative care setting and the role of intravenous iron: a descriptive analysis of hospice data","author":"T Steele","year":"2021","journal-title":"figshare."}],"container-title":["AMRC Open Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/amrcopenresearch.org\/articles\/3-6\/v2\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/amrcopenresearch.org\/articles\/3-6\/v2\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/amrcopenresearch.org\/articles\/3-6\/v2\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,4,12]],"date-time":"2021-04-12T11:22:57Z","timestamp":1618226577000},"score":1,"resource":{"primary":{"URL":"https:\/\/amrcopenresearch.org\/articles\/3-6\/v2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,3,22]]},"references-count":19,"URL":"https:\/\/doi.org\/10.12688\/amrcopenres.12963.2","relation":{"has-review":[{"id-type":"doi","id":"10.21956\/amrcopenres.14052.r26654","asserted-by":"subject"},{"id-type":"doi","id":"10.21956\/amrcopenres.14052.r26654","asserted-by":"object"}]},"ISSN":["2517-6900"],"issn-type":[{"value":"2517-6900","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,3,22]]},"assertion":[{"value":"Indexed","URL":"https:\/\/amrcopenresearch.org\/articles\/3-6\/v2#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.21956\/amrcopenres.14034.r26623, Katalin Urban, Palliative Care Department, Lismore Base Hospital, Lismore, NSW, Australia, 18 Feb 2021, version 1, 1 approved, 1 approved with reservations","URL":"https:\/\/amrcopenresearch.org\/articles\/3-6\/v1#referee-response-26623","order":0,"name":"referee-response-26623","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Thomas Steele<\/b>; \n<i>Posted: 25 Feb 2021<\/i>; Thank you for reviewing our article, your positive feedback and constructive criticisms. We completely agree with your analysis of the limitations of the work, particularly its retrospective design and hope it can be a step towards a prospective study with robust analysis of the effect of iron replacement on symptom burden in future. We have made some amendments based on your comments, which I have explained point by point, along with specific responses to your comments, below.  \n<i>Thank you for this contribution to the literature in managing iron deficiency in the inpatient palliative care setting, and how national guidelines translate to practice in this situation.  There is a typo in the abstract, it is reported that 112 cases had iron status evaluated, representing 25\/110 of those with mild anaemia, 26\/76 with moderate and 41\/54 with severe anaemia, however in the results section it is 46\/76 for moderate anaemia (not 26) - these numbers add up to 112 whereas those in the abstract do not thus I assume are incorrect, please rectify.&nbsp;&nbsp;<\/i> Thank you for pointing this out, we have amended accordingly.  \n<i>The aim and setting are clearly described and the methods section is well written and easy to follow.  Retrospective data collection often does lead to bias and is dependent on documentation quality - in the Design section, it is stated that the documentation of the presence of classic symptoms of anaemia were sought, however this is very heavily reliant on documentation and an absence of documentation does not necessarily mean they were not present.&nbsp;<\/i> Agreed. To make this clearer to the reader we have specified where exactly these were documented (methods section, design) and highlighted reliance on documentation as a limitation.  \n<i>Prospective collection of data would have added a great deal to the validity of this study, with identification of data to be collected in advance - the authors acknowledge this in limitations.<\/i> Hopefully this report will support funding and approvals for a prospective trial.  \n<i>With regards to the protocol for investigating iron deficiency anaemia, it would help reproducibility if the authors could clarify how it was decided if oral\/iv management would be appropriate - especially as in results it states that 6 patients with AID had clear decisions not to treat on clinical grounds.<\/i> Thanks for pointing out the need for more clarity here, we have significantly amended the paragraph \u201cprotocol for interpretation of iron status and managing iron deficiency\u201d to explain the decision-making process more clearly. Table 2 includes the reason why intravenous iron was indicated (final row).  \n<i>Figure 1 is a great visual representation of the diagnostic process.&nbsp; All 3 tables are clear and easy to understand.  Results -&nbsp; A great overview of the change in practice is provided. Whilst the focus was not outcomes, it is reported that 58% had a documented symptom benefit, however there is no further information on which symptoms and what level of improvement. This information, as well as quality of life measures, would add value. I realise that the aim of this study was not to look at outcomes, and as the authors point out further research is needed to clarify this.<\/i> Agreed, this was limited by documentation, now more clearly highlighted as a limitation.  \n<i>I am curious why iron levels were not reported (as they are documented in the raw data).<\/i> Iron levels are reported as part of \u201ciron studies\u201d in our locality but aren\u2019t felt to be a reliable indicator of iron status in isolation and ferritin primarily and, in the context of inflammation, transferrin saturation recommended to inform decision making. Ref 11 gives some more detail about the complex area of functional iron deficiency relevant here. In order to make as relevant as possible to clinical practice we therefore reported ferritin\/TSAT in the main manuscript but were keen to ensure all parts of iron studies were included in raw data in case of interest to groups in the future.  \n<i>It is interesting to note, when the raw data is reviewed, that only 2 of the 12 patients treated with iv iron had an MCV over 80 - this is not commented on, though it is discussed that lower MCV does correlate with iron deficiency as expected. I would be interested to hear what the authors make of this. Is this a coincidence?<\/i> Thanks for this, it is an interesting observation, especially as in the AID group as a whole the mean MCV is over 80. It is possible that lower MCV could have influenced clinician judgement- in particular the perceived likelihood of iron replacement being helpful. It would be interesting to see this being reported in further studies. Or it could be an observation that would disappear with a larger sample of IV iron patients. A particular area where we need more evidence is functional iron deficiency in which a low MCV wouldn\u2019t typically be seen.  \n<i>A great start to showing that implementation of guidelines is possible and that iron infusions seem doable and safe n the hospice setting. In terms of future directions, a prospective study evaluating the overall benefit to patients would be a great next step.<\/i>  Thanks again for the time spent reviewing our work.","URL":"https:\/\/amrcopenresearch.org\/articles\/3-6\/v2#referee-comment-3086","order":1,"name":"referee-comment-3086","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.21956\/amrcopenres.14052.r26654, Edward A. Dickson, National Institute for Health Research Biomedical Research Unit, Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, UK, 12 Apr 2021, version 2, indexed","URL":"https:\/\/amrcopenresearch.org\/articles\/3-6\/v2#referee-response-26654","order":2,"name":"referee-response-26654","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. The roles of all of the authors are supported by Marie Curie. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":3,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}