Актуальная Медицина - Anaemia: Introduction

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Anaemia: Introduction
 
Anaemia is a deficiency in the quality or quantity of red blood cells, which leads to the development of various types of disease manifestation. Thus, special blood tests are usually used to determine the exact type of anaemia.
There are the following types of anaemia:

- Hookworm anaemia (due to the development of hookworm infection).
- Iron deficiency anaemia (due to the blood loss).
The red cells may be depleted by loss of blood from the body.
- Aplastic anaemia (due to the rapid reduction of red cells in number).
- Haemolytic anaemia (due to the rapid destruction of the red cells).  
- Sickle cell anaemia (inherited disorder of the haemoglobin).

Anaemia is common in severe malaria as well. It is often associated with secondary bacterial infection.
Anaemia is an important complication of malaria in young children and in pregnant women.
Other diseases may also produce anaemia: cancer, leukaemia, tuberculosis, nephritis, rheumatic fever, erythroblastosis of newborn (RH-disease).
The most common type of anaemia in children is simple iron deficiency anaemia (due of heavy consumption of milk).
Iron is an essential building block in the formation of haemoglobin in the blood. At the puberty an inadequate diet and rapidly growing organism may result in a form of anaemia (the green sickness – chlorosis).
The answers to the following four fundamental questions are always relevant to a complete evaluation of the anaemia patient:
1. Is there evidence of iron deficiency?
2. Is the anaemia megaloblastic?
3. Is there evidence of haemolysis?
4. Is the bone marrow hypoactive?
Iron deficiency must be considered in all anemias of obscure origin – regardless of red cell morphology.
The combination of low serum iron and elevated total iron-binding capacity is seen only in iron deficiency anaemia.
If these tools are not available, recourse must be had to obtaining a history of blood loss or evidence of it by stool guaiacum determination.
The major haemolytic disorders, regardless of type, have in common:
1. retyculocytosis;
2. slightly increased serum bilirubin; 
3. an increased number of nucleated red cells in the marrow.
In any case of undiagnosed normocytic anaemia which does not fall into the above 4 groups
  The following causes must be considered:
- infection;
- azotemia;
- malignancy;
- myxedema;
- liver disease.
The red cells may be depleted by loss of blood due to repeated bloody noses, bleeding ulcers or fissures, abnormally heavy menstrual flow.

Symptoms and signs of hookworm anemia:

- chronic infections - хронічні інфекції
- hypoalbuminaemia - гіпоальбумінексія
- haemoglobin levels are very low - рівні гемоглобіну дуже низькі
- patients may complain of general weakness, of being easily fatigued and of shortness of breath on exertion - Хворі можуть скаржитися на загальну слабкість, швидку втому і задуху при напруженні
- palpitation - серцебиття
- dizziness - запаморочення
- epigastria pain - біль у районі черевної порожнини
- loss of appetite - втрата апетиту
- men may also complain of impotence - чоловіки також можуть скаржитися на імпотенцію
- several cases of precordial or anginal pain - декілька випадків було у передсерді та грудині
- blurred vision - затуманений зір
- ringing in the ears - дзвін у вухах
- difficulty in swallowing - складність при ковтанні (біль при ковтанні)
- tingling sensation in the hands - відчуття тремтіння у руках
- swelling of the ankles - випуклість, пухлина щиколотки
- pallor of the skin - блідність шкіри
- conjunctivae - кон’юктива, слизова оболонка ока
- tongue and buccal mucosa - слиз на язиці і в ротовій порожнині
- increased pulse pressure - підвищений пульс (артеріальний тиск)
- peripheral vasodilatation - периферійне розширення судин
- increased venous pressure - підвищений венозний тиск
- koilonychias (flattering and concavity of the fingernails) - колонихія, прим’ятість і викривлення нігтів пальців
- angular stomatitis, (which are common in iron deficiency anaemia) - ангулярний стоматит (характерний для анемій, спричинених дефіцитом заліза)
- retinal haemorrhages - кровотечі у районі сітківки ока
Most patients report having had symptoms for only relatively short periods (usually 2-3 months and rarely as long as year) – більшість пацієнтів доповідають про симптоми тільки протягом порівняно коротких періодів (зазвичай 2-3 місяці і зрідка протягом року)
Despite the degree of anemia, most patients do not appear to be really ill – незважаючи на ступінь анемії більшість хворих не виявляються насправді хворими
A minority, however, both look and feel ill, has:
Меншість, однак, виглядає і відчуває себе хворими і проявляє такі симптоми:
- a slow pulse – сповільнений пульс;
- collapsed veins – звужені вени;
- low body temperature (below 36° C) – низька температура тіла (нижче 36° С);
- severe edema (affecting the face, arms, legs) – тяжкий набряк. Який вражає лице, руки і ноги;
- ascites - асцит.
The edema has been attributed to hypoalbuminaemia rather than to the heart failure, which may be present – набряк, скоріше пов’язаний з гіпоальбумінемією (гостра нестача білка), ніж із серцевою недостатністю
 Hookworm infections may be classified into two main groups:
 Нематодні інфекції можна розділити на дві основні групи
- infection with little or no anemia – інфекції з незначною анемією або без неї;
- infection with iron deficiency anemia – інфекції з анемією, спричинені нестачею заліза.
This distinction is of great public health importance in deciding which control measures are most suitable for an infected population. 
Ця відмінність має велике значення для здоров’я населення у вирішенні того, які міри контролю найбільше підходять до зараженого населення.
Children with hookworm anemia may suffer from impaired physical development, apathy, irritability, listlessness and poor academic performance in school. 
Діти із захворюваннями на нематодну анемію можуть страждати від погіршення фізичного розвитку, апатії, роздратованості, в’ялості і поганої академічної успішності в школі.
Pica, a craving to eat non-food substances, including soil may also be observed.
Геофагія (зіпсований апетит) – прагнення їсти неїстівні речовини, пісок, що також характерно.
Hookworm can cause severe and widespread anemia. Нематода може викликати важку (гостру) і широкопоширену анемію
Morbidity and mortality were high - хворобливість і летальність були високими.
Ancylostoma duodenale – анкілостома дванадцятиперстної кишки
miner’s anemia prevalent in many European countries – шахтарська анемія поширена в багатьох європейських країнах.
High ambient temperature – висока оточуюча температура
 humidity plus unhygienic conditions (in mines in temperature zones) – вологість плюс негігієнічні умови (на копальнях у помірних зонах).
Still existing in plantations in tropics and subtropics, hookworm disease may assume epidemic proportions in a labour force if it is not kept under control – все ще поширена на плантаціях в тропіках і субтропіках нематоді захворювання можуть набирати епідемічного характеру серед робітничої сили, якщо не утримувати її під контролем.
In such environments, however, recognition, treatment and prevention of the disease should present little difficulty – Однак, у таких умовах розпізнавання, лікування і запобігання хвороби являє собою складність.
The situation is very different in areas where hookworm infection is endemic, but where transmission and intensity of infection are more moderate in degree – Ситуація дуже відрізняється на територіях, де інфекція нематоди являється епідемічним захворюванням, але де передача та інтенсивність інфекції є більш помірними за обсягом.
The most serious consequence of hookworm infection is chronic blood loss from the small intestine leading to the development if iron deficiency anemia – найбільш серйозний наслідок нематодної інфекції – хронічна втрата крові з тонкої кишки, яка веде до розвитку анемії, спричиненої нестачею заліза.

 Iron balance – баланс заліза:
- a state of precarious iron balance – стан ненадійного балансу заліза
- low dietary intake – низький вміст дієтичного заліза
- Low intestinal absorption of dietary iron – низьке поглинання дієтичного заліза
Chronic blood loss may be sufficient to exhaust body iron stores and induce iron deficiency anemia – хронічні втрата крові може бути достатньою для того, щоб вичерпати запаси заліза і спричинити анемію через дефіцит заліза
This is often the case where rice is the staple food, little meat is eaten, dietary ascorbic acid is low and a high intake of tannins (in tea) impairs iron absorption – це має місце там, де рис – основна їжа, їдять мало м’яса, рівень дієтичної аскорбінової кислоти низький і високий вміст танатів (солей дубильної кислоти) послаблює абсорбцію заліза.

Even small hookworm loads may precipitate severe anemia in children and in women of childbearing age, whose physiological needs for iron are high. Навіть малі відклади нематоди можуть спричинити стрімкий спад тяжкої анемії у дітей і жінок віку, що сприяє народженню дітей, фізіологічні потреби у залізі яких великі.
Hookworm anemia is associated only with much greater intensity of infection – Нематодна анемія пов’язана тільки з більшою інтенсивністю інфекції.
Development of hookworm anemia depends on – розвиток нематодної анемії залежить від:
- The host - iron balance, body iron stores, dietary iron, absorption of iron, physiological requirements, other iron losses – господаря – баланс заліза, запаси заліза, дієтичне залізо, поглинання заліза, фізіологічні вимоги, інші витрати заліза.
- The parasite – hookworm species, hookworm load, duration of infection.

Iron deficiency anaemia (due to the blood loss)

Essential of diagnosis:
- pallor, lassitude;
- hypochromia, microcytosis, RBC less reduced than haemoglobin;
- serum iron low, total iron-binding capacity increased;
- bone marrow hemosiderin absent;
- blood loss usually occult.
- Excessive menstrual flow and gastrointestinal bleeding (due to hiatus hernia, gastritis, peptic ulcer, polyps, malignancy, haemorrhoids, or excessive salicylate intake) are the principal causes.
More iron is absorbed in iron deficiency anaemia.
Chronic bleeding of as little as 2-4 ml of blood per day may lead to a negative iron balance and iron deficiency anaemia.

Clinical findings (symptoms and signs):
- easy fatigability;
- dyspnoea;
- palpitation;
- angina;
- tachycardia;
- waxy pallor;
- brittle hair and nails;
- smooth tongue;
- cheloids;
- dysphagia.

Laboratory findings: 
- The haemoglobin may fall to as low as 3 gm/100 ml.
- The red cells are usually microcytic and hypo chromic. But in 20% of adults – normocytic and nearly normochromic.
- The WBC is normal.
- Serum iron – below 30 mg/100 ml.
- Total iron–binding capacity is elevated to 350-500 mcg/100 ml.
- The most critical test is the bone marrow stain for hemosiderin.
- Stainable iron is always absent in iron deficiency anaemia.
- The bone marrow aspirate contains increased numbers of nucleated red cells.
- The normoblasts have only scanty cytoplasm.
Treatment:
- Iron is specific for this type of anaemia.
- It should be started as soon as an etiologic diagnosis has been made.
- Transfusions are rarely needed.
Give one of the following;
- ferrous sulphate, 0,2 Gm. (3gr.) t. i. d. after meals;
- ferrous gluconate, 0,3 Gm. (5 gr.) t. i. d. after meals.
- Oral iron should be continued for 3 months after haemoglobin values return to normal in order to replenish iron stores.
- Many other iron salts and chelates are not more useful in iron deficiency anaemia than ferrous sulphate.
- Parenteral iron should be given only in the amounts necessary to correct the deficiency.
- The total dosage as follows:
250 mg for each Gm of haemoglobin below normal: men – 14-16 Gm, women – 12-15 Gm.
Iron-dextran injection (5% metallic iron/50 mg/ml). 
Imferon may also be given intravenously (doses of 250-500 mg ), a test dose of 0,5 ml should be given first.
Pernicious anaemia (Addisonian anaemia)

Essentials of diagnosis:
- Anorexia, dyspepsia; smooth sore tongue.
- Constant, symmetric numbness and tingling of the feet.
- Pallor and trace of jaundice.
- Oval monocytes, pancytopenia, hyper segmented neutrophils.
- Megaloblastic bone marrow.
The diagnosis can be based with confidence upon the blood and bone marrow examinations. RBC – below 3 million/cu. mm. Although large red cells are not seen exclusively in the megaloblastic anemias, their oval appearance is characteristic, as are the hyper segmented white cells and the megaloblasts of the marrow.
Pernicious anaemia is a conditioned vitamin B12 deficiency due to an absorption defect, not dietary lack.
Intrinsic factor is absent.
It is more common in persons of Scandinavian, English, and Irish extraction, and is very rare in Orientals.
Predisposition to pernicious anemia is probably inherited as a single, dominant, autosomal factor. About 40% of patients have a 7S gamma "auto-antibody” with activity against intrinsic factor in their serum; approximately twice that many have antibody against parietal cells. Intrinsic factor is secreted by the gastric mucosa; it makes possible absorption of vitamin B12.
Total body vitamin B12 content is estimated to be 5 mg, daily loss is = 2,5 mg. Clinical and haematological evidence of pernicious anaemia appears when the body vitamin B12 pool has been reduced to 10% of normal.
Clinical vitamin B12 deficiency may also be caused by gastroectomy, regional ileitis, certain intestinal malformations involving the ileum, resection of the ileum, and fish tapeworm disease.

Clinical findings (symptoms and sings).
Patients may tolerate their disease well.
Symptoms:
- easy fatigability;
- dyspnoea;
- palpitation;
- angina;
- tachycardia;
- glossitis;
- gastrointestinal symptoms such as: belching , indigestion, anorexia and diarrhoea.
CNS-symptoms (10%):
  - constant symmetric numbness;
- tingling of the lower extremities ;
- ataxia;
- mental disturbances;
- loss of vibration sense;
- deep reflexes.

Laboratory findings.
- There are small misshapen red cells.
- The WBC is usually under 5000/cu. mm.
- The granulocytes, which constitute less than 50% of white cells, tend to be hyper segmented.
- Platelets usually are reduced (40-100 thousand/cu. Mm.)
- Reticulocytes range from less than 1% to 3%.
- The icterus index is increased, but is rarely higher than 15 units.
- The bone marrow is hyperactive and is easily entered with the aspiration needle.
- The characteristic megaloblastic abnormalities are particularly evident in the more mature forms.
- Megakariocytes are hyper segmented and reduced in number.
- Hemosiderin is increased and in the form of fine granules.
- Patients secret no free gastric acid and very little gastric juice, even after injection of histamine or betazole hydrochloride.
- Serum VB12 concentration is less than 100 mg/ml.
- Absorption of Co57-labeled VB12 is greatly impaired (Schilling test).
Less than 5% of the radioactive VB12 is excreted in the urine in 24 hours (normal=15-40%), but simultaneous administration of intrinsic factor increases the excretion of VB12 fivefold or more.

The Schilling test is useful only in:
1. diagnosing addisonian pernicious anaemia from megaloblastic anaemia due to folic acid deficiency;
2. diagnosing addisonian pernicious anemia in remission;
3. diagnosing defective VB12 absorption in patient with combined system disease before the onset of anaemia.

Treatment:
- Vitamin B12 (cyanocobalamin) or vitamin concentrate –100 mcg. 1-3 times per week until blood values return to normal.
- Thereafter 100 mcg. I.M. monthly is given.
- The patient must be impressed that the need for VB12 injections will continue for the rest of his life.
- There is no need for special diets, hydrochloric acid, or folic acid – especially the last, which will not correct neurological changes.
- Hospitalization or bed rest is not necessary unless enforced profound anaemia oak neurological symptoms.
- Patients who have undergone total gastroectomy should receive maintenance doses of VB12 (100 mcg. I.M. monthly).

Folic Acid Deficiency

Produces the same haematological findings as a pernicious anaemia, but blood changes occur much more rapidly (folate storage lasts for only 1-2 months). The most common cause is malnutrition, especially in association with alcoholism ("nutritional megaloblastic anaemia”).

Symptoms:
- chronic diarrhoea;
- abnormal tests.
In megaloblastic anemias due to folic acid deficiency, CNS symptoms are lacking, free gastric acid may be present, and the VB12 absorption test (Shilling) is normal VB12 absorption may be impaired even after administration of intrinsic factor. Serum folate activity is less than 3 mcg/ml. Urine formimunoglutaminic acid after histamine loading is increased.

Treatment:
- folic acid is given orally or i. m., 5 mg. Daily;
- no maintenance therapy is necessary;
- the i. m. preparation contains 15 mg/ml.
Patients with sprue or malabsorption syndrome – initial therapy with parenteral folic acid and maintenance with oral folic acid.

Aplastic anaemia
Essentials of diagnosis:
- Lassitude, pallor, purpura, bleeding.
- Pancytopenia, fatty bone marrow.
- History of exposure to an offending drug or X-ray radiation.
Aplastic anaemia is characterized by pancytopenia or a selective depression of red cells, white cells, or platelets. In over half of cases the aetiology is not known. It may occur as a toxic reaction to many chemical and drugs (chloramphenicol, (chloromycetin), benzene, phenylbutazone (Butazolidin), and methylphenylethylhydatoin (Mesantoin).
Hair dyes, plant sprays, insecticides, volatile solvents, large doses of antileukemic drugs, and excessive X-ray or ionizing radiation may also cause this disease.
In some cases an associated thymoma is found.
Clinical findings (symptoms and signs):
Anaemia may cause lassitude, pallor, fatigue and tachycardia;
With thrombocytopenia is purpura and bleeding;
With neutropenia there may be skin, mucous membrane, and systemic infections with high fever.

Laboratory findings:
• The RBC may be below 1 million/cu. mm.
• The cells are usually macrocytic.
• The retyculocyte count is often low, but may be normal or even slightly elevated.
• The WBC may be less than 2000/cu. mm and the platelet count less than 30 000/cu. mm. 
• The icterus index is usually below normal.
• The bone marrow is fatty.
• There are very few red cells, white cells, and megakaryocytes.
• Hemosiderin is present.
Fixed tissue section made from the marrow aspirate and stained with haematoxylin and eosin are best for demonstrating the characteristic architecture of an aplastic bone marrow.

Treatment:
A. General measures:
Eliminate exposure to suspected toxins and discontinue all unnecessary medication. No agents are known that will be predictably stimulate marrow function, but the following may be treated:
• Vitamin B12, folic acid, and crude liver extract.
• Cobaltous chloride, 100 – 150 mg orally daily for at least 3 weeks.
• Methyl testosterone, 100 mg orally daily or testosterone enanthate in oil, 1 – 2 mg/kg/day I.M. given twice a week.
• Prednisolone (or other corticosteroid), 10 – 20 mg 4 times daily. 
• If a thymoma is present, its removal may be considered.

B. Transfusions:
Give preferably as packed red cells only, less than one week old. Five ml of packed red cells/kg will raise the RBC by 10% (For example, 500 ml of red cells will raise the haemoglobin of a 50 kg patient by 20% or 3 gm /100 ml.). The average requirement for adults is 5 units (2500 ml whole blood or 1250 ml red cells every 2 months.
Post transfusion haemoglobin levels of 11 – 12 gm/100 ml are satisfactory.
Many patients do not have to be transfused until the haemoglobin level falls to less than 7 gm/100 ml. If a febrile transfusion reaction develops, serum should be checked for leuko-agglutinins; if these white cell antibodies have developed, the buffy coats should be removed from all subsequent transfusions.

Haemolytic anemias:
1. Autoimmune haemolytic anaemia.
2. Hereditary spherocytosis (Congenital Haemolytic) anaemia.
3. Ovalocytosis (Hereditary Ellipsocytosis).
4. Acute haemolytic anaemia.
5. Hereditary nonspherecytic haemolytic anaemia.
6. Primaquine – sensitive haemolytic anaemia (and anemias due to other drug sensitivities).
Autoimmune haemolytic anaemia:
Essentials of diagnosis:
• Fatigue, malaise, pallor, jaundice.
• Splenomegaly.
• Persistent anaemia and retyculocytosis.
• Coombs test usually positive.

General considerations:
The red cells abnormality is usually non-specific, but rare blood group antibodies (anti-E or anti-e) are occasionally found.
Some red cells are agglutinated.
This type of haemolytic anaemia develops during the course of about 30% of cases of chronic lymphatic leukaemia, and accompanies or precedes some cases of Hodgkin’s diseases, macroglobulinemia, lupus erythematosysus.
No specific aetiology is found in about two-thirds of cases.

Clinical Findings (Symptoms and signs).
Symptoms of anaemia (weakness, pallor, dyspnoea, palpitation, dizziness) or haemolysis (fever, jaundice, splenomegaly, hepatomegaly ) may be present.

Laboratory findings:
Acquired haemolytic anaemia is usually normocytic and normochromic.
Spherocytes and nucleated red cells may be seen.
White cell and platelet counts are frequently elevated, but leucopoenia and thrombocytopenia may occur.
Reticulocytes are usually in excess of 10%; occasionally they are low.
The bone marrow shows marked erethroid hyperplasia and ample hemosiderin. There is no bile in urine.
Stool urobilinogen may be greatly increased.

Treatment:
Transfusions are only palliative, and their effects are dissipated rapidly since donor cells are also destroyed at an accelerated rate.
Prednisolone (or equivalent) 10–20 mg 4 times daily (orally) until normal haemoglobin values are reached.
Patients must be re-examined every 4 weeks even when in remission because there is always a danger of sudden relapse. 
Acute haemolytic anaemia.
Essentials of diagnosis:
• Sudden onset with chills, fever, nausea, vomiting, or pain in abdomen or back.
• Pallor, slight jaundice, splenomegaly.
• Red or black urine.
The abdominal pain may suggest surgical illness; the profound anaemia may suggests blood loss. The serum is invariably pigmented as a result of the products of haemolysis. A pink serum indicated free haemoglobin; a brown serum – methemalbumin; a yellow serum – bilirubin.
Acute haemolytic anaemia may be drug-induced, especially in sensitive individuals, it may be due to certain infections.

Symptoms and signs:
The disease has a fulminating onset with chills. Weakness and tachycardia may be present also.
Laboratory findings:
Spherocytes, burr cells, and nucleated red cells may be seen.
RBC and haemoglobin are lowest several days after the onset of symptoms.
The WBC may reach 50000/cu. mm and the platelet count 1million/cu.mm, but occasionally both are decreased.
Reticulocytes may be greatly increased. The Coombs test is usually negative. The bone marrow is hypo plastic, with a predominance of nucleated red cells. Haptoglobin disappears from the serum.
The urine may contain haemoglobin and hemosiderin, and urobilinogen may be elevated. Stool urobilinogen is increased.
Glucose-6-phosphate dehydrogenase deficiency.

Treatment.
Acute haemolytic anaemia may be a medical emergency.
The patient should be hospitalized, all medications discontinued and possible causes investigated. Even patients who are not critically ill are observed for a few days for a gradual decline of reticulocutosis, followed by a haemoglobin rise of 1 – 2 gm/100 ml/ week. Under these circumstances only supportive therapy need be given.
Strict attention is paid to fluid intake and output, and electrolyte administration.
Transfusions: used to combat shock or anoxia; packed red cells are preferable to whole blood. Rarely is it necessary or desirable to raise the haemoglobin level above 8 gm/100 ml with transfusions.

Sickle cell anaemia.
Essentials of diagnosis:
• Recurrent attacks of fever, and pain in the arms, legs, or abdomen since early childhood in a Negro patient.
• Anaemia, jaundice, retyculocytosis, positive sickle cell test and demonstration of abnormal (S) haemoglobin, blood cloths, stroke.
• The spleen is not enlarged in adult sickle cell anaemia. An anaemic Negro patient with an enlarged spleen and a positive sickle cell preparation probably has a double heterozygous disorder instead (e.g. "sickle thalassemia” rather than sickle cell anaemia). The sickle cell test doesn’t reliably differentiate between sickle cell anaemia (the homozygous disorder) and sickle cell trait (the heterozygous carrier state).
• RBC is always low.
• Negro patient suggests iron deficiency anaemia plus sickle cell trait. Sickle cell anaemia is a hereditary disorder, essentially confined to Negroes; the abnormal haemoglobin is transmitted as a single dominant gene.

Symptoms and signs:
The diagnosis is usually made in childhood, but occasionally a patient will reach adult life before a well documented crisis develops. Patients tend to be of asthenic build with long spindly legs. Constant sclera icterus of moderate degree is common. 
The crisis consist of:
• Attacks of bone and joint pain.
• Abdominal pain, sometimes with fever (resembles surgical illness). Cerebral thrombosis may occur, producing headaches, paralysis and convulsions.

Laboratory findings:
• Anaemia is moderately severe (RBC is usually 1,5 – 2,5 million/cu mm).
• Normocytic and normochromic. 
• Some sickle cells are usually present on the blood smear.
• Reticulocytes may be 15 – 20%.
• A WBC of 20 – 30 thousand is not unusual during painful crisis.
• 100 nucleated red cells per 100 white cells.
• The bone marrow shows marked erythroid hyperplasia, with more nucleated red cells than white cells.

Treatment:
Treatment is symptomatic.
• Place the patient at the bed rest and give analgesics.
• Local measures, cobalt, nasal oxygen, carbonic anhydrase inhibitors.
• Sodium bicarbonate, 3,5 m Eq/kg/hour I.V., or plasma expanders (dextran).
• Plasma and glucose solution with 0,45% sodium chloride solution.
• Pulmonary thrombosis and osteomyelitis are treated by standard methods.

Body iron stores:
1) metabolically active iron (in haemoglobin, myoglobin, various enzymes)
2) storage iron (in ferritin and hemosiderin)
Women have lower iron stores than men – (1/3)

Indications for blood Transfusion: (Вказівки для переливання крові)
Вторинна анемія – secondary anaemia
Крововтрата – blood loss
Виражена анемія – severe (marked, pronounced) anaemia
Жорстка анемія – acute anaemia
Гемолітична анемія – hemolytic anaemia
Постгемморрагічна анемія – post hemorrhagic anaemia

Хворий намагається боротися з анемією – The patient tries to combat anaemia
Вам усунуть анемію, використовуючи процедуру лікування та переливання – They’ll correct your anemia, using the procedure of treatment and blood transfusion.

Plasma substitutes (blood substitutes, blood substitute solutions, hemocorrectors, blood substitute liquids) – плазмозамінники (кровозамінники, кровозамінні розчини, гемокоректори, кровозамінні рідини).

Амінокровін – aminokrovin
Гемодез – hemodez
Маннітол – mannitol
Поліглюкін – polyglucin
Ізотонічний розчин хлориду натрію - isotonic solution of sodium chloride
Розчин Рінгера-Лока – Ringer-Locks solution

Blood preparations (препарати крові)
Альбумін – albumin
Плазма – plasma
Протеїн – protein
Лейкоцитарна маса – packed white cells
Тромбоцитарна маса – platelet concentrate
Еритроцитарна маса – packed red cells
Ліофілізована плазма – lyophilized plasma
Нативна плазма – native plasma
Суха плазма – dried plasma.

Speech patterns 
Визначте групову сумісність (індивідуальну сумісність, біологічну сумісність, резус-фактор) – Determine group compatibility (individual compatibility, biological compatibility, Rhesus blood factor)
Реакція аглютинації сумнівна – the agglutination reaction is doubtful 
Підготуйте систему для переливання крові – get the system for blood transfusion ready.
Негайно встановіть систему для внутрішньовенного вливання – Adjust (get) the drip stand immediately
Дослідіть взяту порцію крові на стерильність (реакція Вассермана) – Examine the blood taken for sterility (Wassermann’s test)
Ви хворіли на вірусний гепатит (малярію, сифіліс) – You had virus hepatitis (malaria, syphilis)
Підготуйте все для аутореінфузії – Get ready for autoreinfusion
Візьміть ампулу із консервованою кров’ю. Bизначте придатність крові для переливання - Take an ampoule with with conserved blood. Determine, if the blood is fit for transfusion.
Кров має згустки. Плазма мутнувата (з плівками) – There are clots in the blood. The plasma is turbid (with flakes, films)
Кров непридатна для переливання. Перевірте кров на гемоліз – The blood is not fit for the transfusion. Examine the blood for signs of haemolysis.
Яка реакція хворого на переливання крові? – What is the patient's reaction for blood transfusion?
Хворий жаліється на тиск в грудях (різкий біль у районі поясниці, різкі болі внизу живота, тошноту) – The patient complains of compression in the chest (sharp pains in the lumbar region, sharp pains in the lower abdomen, nausea)
У хворого з’явилися ознаки хвилювання (судоми, ціаноз, швидкий пульс, зниження артеріального тиску) – The patient has shown some signs of disturbance (cramps, cyanosis, rapid pulse, drop in the arterial pressure).
Капельно перелийте 500-700 мл одногрупної індивідуально і біологічно сумісної крові – Transfuse drop by drop 500-700 ml of blood which is identical to that of the patient in group, individual and biological compatibility.
Проведіть замінне переливання крові – Perform exchange blood transfusion.
У хворого розвинулася гостра анемія – The patient has developed severe anemia.
У хворого всі ознаки постгеморальної анемії – The patient has all the signs of post haemorrhagic anaemia.
Проливання крові протипоказане – Blood transfusion is contraindicated.
У випадку необхідності робіть переливання крові – If necessary give blood transfusion.
Дайте мені ампулу сухої плазми і ампулу бідистильованої води – Will you give me an ampoule with dried plasma and an ampoule with double-distilled water?
У хворого виражена лейкопенія (апластична анемія) – The patient has pronounced leucopenia (aplastic anaemia)
Перелийте 250 мл лейкоцитарної (еритроцитарної, тромбоцитарної) маси – Transfuse 250 ml of white cell (red cell, platelet) concentrate.
Коли лікувати анемію дефіциту заліза за допомогою заліза, прояв максимально сформованої клітини еритропоезу з’являється на 5 чи 8 день – When treating iron deficiency anemia with iron, the maximal reticulocyte response occurs in the 5-th to 8-th day.

Vocabulary

manifestation [mənǐfǐs`teǐ∫n] прояв
to determine [dǐ`tə:mǐn] визначати
absorption [əb`so:p∫n] споживання, всмоктування, абсорбція
maturation [mətјυ`reǐ∫n] дозрівання
obvious [`obvǐəs] очевидний
to be depleted [dǐ`pli:tǐd] бути виснаженим
bone marrow [`bəυn`mærəυ] кістковий мозок
destruction [dǐs`trǎk∫n] руйнування
consumption [kən`sǎmp∫n] споживання
administration [ədmǐnǐs`treǐ∫n] застосування
puberty [`pјu:bətǐ] пубертатний період
deficiency [dǐ`fǐ∫ǐənsǐ] дефіцит, нестача
relevant [`relǐvənt] відносний, релевантний
evaluation [ǐvəlјυ`eǐ∫n] оцінка
serum iron [`serəm` a ǐən] сироватка заліза
elevated [ǐlǐ`veǐtǐd] підвищений
regardless [rǐ`gα:dlǐs] безвідносно
capacity [kə`pæsǐtǐ] здатність
available [ə`veǐləbl] наявний
to obtain [əb`teǐn] набувати
haemolytic disorders 
[hemə`lǐtǐk dǐs`o:dəz] гемолітичні захворювання
causes [ko:zǐs] причини
to consider [kən`sǐdə] розглядати
malignancy [mə`lǐgnənsǐ] злоякісність
fissures [`fǐsјυs] надрізи
menstrual flow [`menstrυəl`fləυ] менструальний потік
amounts [ə`ma υnts] кількості, розміри
below [bǐ`ləυ] нижче
sickle-cell anaemia [`sǐkl`sel ənǐ`mi:ə] серповидно-клітинна анемія
substance [`sǎbstǐns] речовина
red blood cells [`red`blǎd`selz] еритроцити
white blood cells [`wa ǐt`blǎd`selz] лейкоцити
collapsed [kə`læpst] стиснутий
oxygen-carrying capacity [`oksǐdзǐn`kærǐ ǐŋ kə`pæsǐtǐ] здатність транспортувати кисень
digestive trouble [da ǐ`dзestǐv`trǎbl] проблема з травленням
supplemental [səplǐ`mentl] додатковий
sufficient [sə`fǐ∫ǐənt] достатній
reserves diminish [rǐ`zə:vz dǐ`mǐnǐ∫] запаси скорочуються
essentials [ǐ`sen∫ǐəlz] основи
species [`spi:∫əz] види
duration of infection 
[dјυ`reǐ∫n əv ǐn`fek∫n] тривалість інфекції
occult [o`kǎlt] прихований
excessive [ǐk`sesǐv] надмірний
hiatus [ha ǐ`eǐtəs] пропуск, зіяння
salicylate [`sælǐsǐ`leǐt] селісиліт
fatigability [fətǐgə`bǐlǐtǐ] втомлюваність
lassitude [`læsǐtјυd] в’ялість, втомлюваність, апатія
palpitation [pəlpǐ`teǐ∫n] серцебиття
pallor [`pælə] блідність
smooth [`smu:θ] гладкий
stain [`steǐn] пляма
nucleated [nјυklǐ`eǐtǐd] зародковий
scanty [`skæntǐ] нечисленний
rarely [`reəlǐ] рідко, зрідка
dosage [`dosədз] дозування
intravenously [ǐntrə`vi:nǐəslǐ] внутрівенно
drugs [`drǎgz] ліки
heart failure [`hα:t`feǐlυə] серцева недостатність
genetic trait [dзǐ`netǐk`treǐt] генетична риса
resistance [rǐ`zǐstəns] спротив, опір
iron medication [`aǐən mǐdǐ`keǐ∫n] лікування залізом
intake [ǐn`teǐk] вміст
fortification [fotǐfǐ`keǐ∫n] підкріплення
to interfere with [ǐntə`fǐə wǐð] заважати
indications [ǐndǐ`keǐ∫nz] показання
deterioration [dǐtǐrǐə`reǐ∫n] погіршення
iron solutions [`a ǐən sə`lu:∫nz] розчин заліза
acute cardiac dilatation [`ækјυt`kα:dǐək dǐlə`teǐ∫n] гостре розширення серця
haemoglobin level [`heməgləυbǐn] рівень гемоглобіну
assessing [ə`sesǐŋ] оцінка
morbidity [mo:`bǐdǐtǐ] хворобливість
inherited [ǐn`herǐtǐd] успадкований
malformation [məlfə`meǐ∫n] неправильне утворення
extremities [ǐks`tri:mǐtǐz] кінцівки
findings [`fa ǐndǐŋz] результати
dyes [`da ǐs] фарбувальні речовини
to discontinue [dǐskən`ti:nјυ] припинити
recurrent [rǐ`kǎrǐnt] повторюваний
to replenish [rǐ`plænǐ∫] поновлювати
blood stores [`blǎd`sto:z] запаси крові
to prevent [prǐ`vent] запобігати
to replace [rǐ`pleǐs] замінювати
numbness [`nǎmnǐs] оціпеніння
jaundice [`dзo:ndǐs] жовтяниця
intrinsic factor [ǐn`trǐnzǐk`fæktə] притаманний фактор
predisposition [prǐdǐspə`zǐ∫n] схильність
mucus [`mјu:kəs] слиз
platelets [`plætǐlǐts] тромбоцити
icterus [`ǐktərǐs] жовтяниця
maintenance [`meǐntənəns] підтримування
initial [ǐ`nǐ∫ǐəl] початковий
sprays [`spreǐs] розпилювання
solvents [`solvənts] розчинники





Training exercises:

Ex. 1. Choose the wrong variant below:

I. Symptomatic haemolytic anemias include the haemolytic anemias that occur with: Except one:
a) Infectious mononucleosis
b) Chronic lymphatic leukaemia
c) Hodgkin's disease
d) Disseminated lupus erythematosus
e) Chickenpox

II. Haemolytic anemias are usually associated with: Except one:
a) increased white cell survival
b) decreased red cell survival
c) increased numbers of reticulocytes
d) increased faecal urobilinogen
e) increased urine urobilinogen

III. Folic acid, when administered to patients with pernicious anaemia is capable of producing the following: Except one:
a) A haematopoietic response
b) Belief of the glossitis
c) An exacerbation of the neurological signs
d) A further lowering of the serum B12 level
e) Increased haemoglobin

IV. Extra corpuscular causes of haemolytic anaemia are the following: Except one:
a) Malaria 
b) Bartonella
c) Clostridium welchi
d) Vibrio comma
e) Tuberculosis

V. Sickle cell anaemia is usually associated with the following: Except one:
a) Haemoglobin S
b) Small or normal sized spleen
c) increased level of white cells
d) shortened erythrocyte life span
e) normal haemoglobin concentration in the red blood cell



Ex 2. Complete the following conversation:
Doctor:
Patient: Hello, Doc. I need your consultation concerning my malaise and weakness. The matter is that I've got some complains of general loss of appetite and fatigability. Sometimes I have anorexia and tingling of my feet and hands.
Dr.:
Patient: Oh, yes, doc, sometimes I have dizziness, my vision is blurred.
Dr.:
Patient: Should I give my blood for examination?
Dr.:
Patient: Yesterday I took my blood pressure. It was rather high.
Dr.:
Patient: Well, doctor. Would you recommend me to be admitted to the hospital for some further examinations
Dr.:
Patient: Thank you doctor. I'll follow your good advise. I'll go and make my preliminary tests and bring you my laboratory findings.
Dr.:

Ex. 3. Answer the following questions:
1) What do the major haemolytic disorders have in common?
2) What does the development of hookworm anaemia depend on?
3) What signs and symptoms f iron deficiency anaemia do you know?
4) Do we need blood transfusion in case of iron deficiency anaemia?
5) May B12 deficiency in case of Pernicious anaemia depend on some other causes?
6) Do we need any maintenance therapy in case of Folic acid deficiency?
7) What is the treatment of autoimmune anaemia?
8) Give a short characteristic of Laboratory findings of acute haemolytic anaemia.
9) Give essentials of diagnosis for Sickle-cell anaemia.
10) Should we use some distinctive features of anaemia to start the corresponding procedure of treatment? What are they?

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