1. BLOOD

2. Anaemia: Anemia ( meaning lack of blood ) is a decrease in number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin deficiency.

7. WHO's Hemoglobin thresholds used to define anemia (1 g/dL = 0.6206 mmol/L) Age or gender group Hb threshold (g/dl) Hb threshold (mmol/l) Children (0.5–5.0 yrs) 11.0 6.8 Children (5–12 yrs) 11.5 7.1 Teens (12–15 yrs) 12.0 7.4 Women, non-pregnant (>15yrs) 12.0 7.4 Women, pregnant 11.0 6.8 Men (>15yrs) 13.0 8.1

8. Peripheral blood smear microscopy of a patient with iron-deficiency anemia.

12. Normocytic: Normocytic anemia: Normocytic anemia occurs when the overall hemoglobin levels are always decreased, but the red blood cell size (Mean corpuscular volume) remains normal. Causes include: Acute blood loss Anemia of chronic disease Aplastic anemia (bone marrow failure) Hemolytic anemia

13. Dimorphic: When two causes of anemia act simultaneously, e.g., macrocytic hypochromic, due to hookworm infestation leading to deficiency of both iron and vitamin B 12 or folic acid or following a blood transfusion more than one abnormality of red cell indices may be seen. Evidence for multiple causes appears with an elevated RBC distribution width (RDW), which suggests a wider-than-normal range of red cell sizes.

14. Heinz body anemia: Heinz bodies form in the cytoplasm of RBCs and appear like small dark dots under the microscope. There are many causes of Heinz body anemia, and some forms can be drug induced. It is triggered in cats by eating onionsor acetaminophen (paracetamol). It can be triggered in dogs by ingesting onions or zinc, and in horses by ingesting dry red maple leaves

15. Refractory anemia : Refractory anemia is an anemia which does not respond to treatment. It is often seen secondary to myelodysplastic syndromes. Iron deficiency anemia may also be refractory as a clinical manifestation of gastrointestinal problems which disrupt iron metabolism

16. Iron regulation and metabolism

26. Iron Absorption Procedure Iron absorption in the human body takes place through the digestive tract, most importantly the small intestine . The remaining organs of the digestive system always contribute their bit to breaking down of food matter. However, the important part comes when the iron from the food source gets assimilated into the blood flow and into the hemoglobin. This process is aptly termed as the 'absorption' of iron. In human body, the small intestine is classified into different parts. The duodenum is the first part and is the place of iron absorption. This process of absorption is initiated by a class of cells that is termed as enterocytes. These cells are present in the inner glycocalyx surface of the duodenum, of the small intestine. The glycocalyx, is an extracellular polymeric surface that is secreted by the cells themselves.

27. Moving on to the chemical procedure of the iron absorption, it must be noted that irons that are a part of the protein, are usually absorbed by the body. This 'absorbable' iron containing protein is often referred to as the heme protein. The ferrous form of this protein is chemically represented as Fe 2+ . Not all dietary irons are in this form, and some of them have to be reduced down from Fe 3+ . This function is conducted at the 'brush border', where a ferric reductase enzyme (a type of enzyme), duodenal cytochrome B, reduce it down to Fe 2+ . The process of conversion finishes here and a protein by the name DMT1, which is also known as divalent metal transporter 1, transports the iron into the cell. There are some very complex procedures that are involved in later stages where the iron optimizes the oxygen carrying capacity of the hemoglobin.

52. TREATMENT

53. Iron : Iron is normally taken in the form of ferrous sulfate. Although other iron salts are commercially available and make claims of fewer or less severe side effects, these benefits may be related to the fact that other preparations contain less iron by weight. Ferrous sulfate contains about 37% iron, while ferrous gluconate contains only about 13% iron. People who have trouble with the side effects of ferrous sulfate may benefit from some of the specialty preparations available, but ferrous sulfate normally offers the greatest amount of iron of all commercial products.

54. Recommended dosage : Dosage should be calculated by iron needs, based on laboratory tests. Recommended one tablet a day, containing 65 mg of iron, as a supplement for patients over the age of 12 years.

55. Precautions Iron can lead to lethal poisoning in children. All iron supplements should be kept carefully out of reach of children. Some types of anemia do not respond to iron therapy, and the use of iron should be avoided in these cases. People with acquired hemolytic anemia, autoimmune hemolytic anemia, hemochromatosis, hemolytic anemia and hemosiderosis should not take iron supplements. Iron supplements should also be avoided by people who have gastric or intestinal ulcers, ulcerative colitis, or Crohn's disease. These conditions marked by inflammation of the digestive tract, which would be made worse by use of iron.

56. Side effects : The most common side effects of iron consumption are stomach and intestinal problems , including stomach upset with cramps, constipation, diarrhea, nausea , and vomiting . At least 25% of patients have one or more of these side effects. The frequency and severity of the side effects increases with the dose of iron. Less frequent side effects include heartburn and urine discoloration.

57. Interactions Iron supplements should not be taken at the same time as antibiotics of either the tetracycline or quinolone types. The iron will reduce the effectiveness of the antibiotic. Also, iron supplements reduces the effectiveness of levodopa , which is used in treatment of Parkinson's disease . Iron supplements should not be used with magnesium trisilicate , an antacid , or with penicillamine , which is used for some types of arthritis. Taking iron with vitamin C increases the absorption of iron, with no increase in side effects.

58. Folic acid : Folic acid is found in many common foods, including liver, dried peas, lentils, oranges, whole-wheat products, asparagus, beets, broccoli, brussel sprouts, and spinach. However, in some cases, patients have difficulty absorbing folic acid or in converting it from the form found in foods to the form that is active in blood formation. In these cases, folic acid tablets are appropriate for use.

59. Recommended Dose : For treatment of anemia, a daily dose of 5 mg is generally used. Patients who have trouble absorbing folic acid may require higher doses. Maintenance doses are: infants: 0.1 mg/day children (under 4 years of age): up to 0.3 mg/day children (over 4 years of age) and adults: 0.4 mg/day pregnant and lactating women: 0.8 mg/day

60. Precautions: Before treating an anemia with folic acid, diagnostic tests must be performed to verify the cause of the anemia. Pernicious anemia caused by lack of vitamin B 12 shows symptoms that are very similar to those of folic acid deficiency but also causes nerve damage which shows up as a tingling sensation and feelings of numbness. Giving folic acid to patients with B 12 deficiency anemia improves the blood cell count, but the nerve damage continues to progress.

61. SIDE EFFECTS. Folic acid is considered extremely safe, and there are no predictable side effects. Where side effects have been reported, they have been among patients taking many times more than the normal therapeutic dose of the drug. On rare occasions allergic reactions to folic acid have been reported.

62. INTERACTIONS. Phenytoins , used to treat seizure disorders, interact with folic acid with a reduction in phenytoin effectiveness and an increased risk of seizures. If the two drugs must be used together, phenytoin blood levels should be monitored, and the dose may have to be increased. Trimethoprim (an antibacterial) and Methotrexate (originally an anti-cancer drug, which is also used for arthritis and psoriasis) act by reducing the metabolism of folic acid. Regular blood monitoring is required, and dose adjustments may be needed.

63. Vitamin B 12 is also known as cyanocobalamine and hydroxocobalamine. Cyanocobalamine may be given by mouth, while hydroxocobalamine must be injected. The vitamin has many functions in the body, including maintaining the nervous system, but in treatment of anemia B 12 is needed for the metabolism of folic acid. Lack of B 12 causes pernicious anemia, a type of anemia which is marked by a low red cell count and lack of hemoglobin. There are many other symptoms of pernicious anemia, including a feeling of tingling or numbness,shortness of breath, muscle weakness, faintness, and a smooth tongue. If pernicious anemia is left untreated for more than three months, permanent damage to the nerves of the spinal cord may result.

64. Recommended Dose : While vitamin B 12 can be given by mouth for mild vitamin deficiency states, pernicious anemia should always be treated with injections, either under the skin (subcutaneous) or into muscle (intramuscular). Hydroxocobalamine should only be injected into muscle. Intravenous injections are not used because the vitamin is eliminated from the body too quickly when given this way. Elderly patients, whose ability to absorb vitamin B 12 through the stomach may be impaired, should also be treated with injections only. The normal dose of cyanocobalamine is 100 mcg (micrograms) daily for six to seven days. If improvement is seen, the dose may be reduced to 100 mcg every other day for seven doses and then 100 mcg every three to four days for two to three weeks. After that, monthly injections may be required for life.

65. PRECAUTIONS. Although vitamin B 12 has a very high level of safety, commercial preparations may contain preservatives which may cause allergic responses. In patients with pernicious anemia, treatment with vitamin B 12 may lead to loss of potassium. Patients should be monitored for their potassium levels.

66. SIDE EFFECTS. Diarrhea and itching of the skin have been reported on rare occasions. Moreover, there have been reports of severe allergic reactions to cyanocobalamine.

67. INTERACTIONS. Aminosalicylic acid may reduce the effectiveness of vitamin B 12 . Also, Colchicine , a drug used for gout, may reduce the effectiveness of vitamin B 12 . Other, infrequently used drugs and excessive use of alcohol may also affect the efficacy of vitamin B 12 .

68. Anabolic steroids : The anabolic steroids ( nandrolone, oxymetholone, oxandrolone, and stanzolol ) are the same drugs that are used improperly by body builders to increase muscle mass. Two of these drugs, nandrolone and oxymetholone, are approved for use in treatment of anemia. Nandrolone is indicated for treatment of anemia caused by kidney failure, while Oxymetholone may be used to treat anemia caused by insufficient red cell production, such as aplastic anemia. All anabolic steroids are considered to be drugs of abuse under F.D.A and only recommended under certain circumstances.

69. RECOMMENDED DOSAGE. The information that follows is specific only to oxymetholone; however, the warnings and precautions apply to all drugs in the class of anabolic steroids. The dosage of oxymetholone must be individualized. The most common dose is 1 to 2 mg per kilogram of body weight per day, although doses as high as 5 mg per kilogram per day have been used. The response to these drugs is slow, and it may take several months to see if there is any benefit.

70. PRECAUTIONS. All anabolic steroids are dangerous. The following warnings represent the most significant hazards of these drugs. Peliosis hepatitis , a condition in which liver and sometimes spleen tissue is replaced with blood-filled cysts, has occurred in patients receiving androgenic anabolic steroids. Although this condition is usually reversible by discontinuing the drug, if it is left undetected and untreated, it may lead to life-threatening liver failure or bleeding.

71. Liver tumors may develop. Although most of these tumors are benign and will go away when the drug is discontinued, liver cancers may also result. Anabolic steroids may cause changes in blood lipids, leading to atherosclerosis with greatly increased risk of heart attack. Because anabolic steroids are derived from male sex hormones, masculinization may occur when they are used by women. Elderly men who use these drugs may be at increased risk of prostate enlargement and prostate cancer.

72. Increased water retention due to anabolic steroids may lead to heart failure. Anabolic steroids should not be used during pregnancy, since this may cause masculinization of the fetus. Anabolic steroids should be used in children only if there is no possible alternative. These drugs may cause the long bones of the legs to stop growing prematurely, leading to reduction in adult height. Regular monitoring is essential. In patients with epilepsy, the frequency of seizures may be increased. In patients with diabetes, glucose tolerance may be altered. Careful monitoring is essential.

73. SIDE EFFECTS. The list of side effects associated with anabolic steroids is extremely long. The following list covers only the most commonly observed effects: acne increased urinary frequency breast growth in males breast pain persistent, painful erections masculinization in women

74. INTERACTIONS : Anabolic steroids should not be used in combination with anticoagulants such as warfarin . Anabolic steroids increase the effects of the anticoagulant, possibly leading to bleeding. If the combination cannot be avoided, careful monitoring is essential.

75. Erytropoetin : Erythropoietin is a glycoprotein hormone that controls erythropoiesis, or red blood cell production. It is a cytokine for erythrocyte (red blood cell) precursors in the bone marrow and has its primary effect on red blood cells by promoting red blood cell survival through protecting these cells from apoptosis. It also cooperates with various growth factors involved in the development of precursor red cells. And A similar drug, darepoetin alpha , is available with the same properties, but it remains active longer and so requires fewer injections each week. Epoetin alpha is approved by the Food and Drug Administration for the following uses: anemia associated with chronic renal failure anemia related to zidovudine therapy in HIV-infected patients anemia in cancer patients on chemotherapy reduction in blood transfusions in surgical patients

76. RECOMMENDED DOSAGE.: Dosing schedules may vary with the cause of the anemia. All doses should be individualized. In general, epoetin alpha dosing in adults is started at 50 to 100 units per kilogram given three times a week, either by vein or subcutaneously.

77. PRECAUTIONS. Epoetin alpha should not be given to patients with severe, uncontrolled hypertension. Other conditions in which epoetin alpha should be used only when the benefits clearly outweigh the risks are as follows: constitutional aplastic anemia hypertension thromboembolism

78. Side effects : The most common adverse effects of erythopoetin alpha are: joint pain chest pain diarrhea swelling fatigue fever weakness headache high blood pressure irritation at injection site nausea vomiting rapid heart beat

79. THANK YOU