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#1
10.03.2006, 18:50
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Анемии
На этой недели была совершенно замечательная лекция по анемиям. Попыталась выложить 2 таблицы очень удобные для работы. Если не получится, попробую еще раз.
Нет, не получается...Не сжимается до нужных размеров...  Ладно, подумаю, что можно сделать.
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#2
10.03.2006, 20:01
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Анемии
Ждем. [Изображения доступны только зарегистрированным пользователям]
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#5
11.03.2006, 10:51
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Прицепились!!! В первом сообщении про анемию.
Если что-то нечетко, скажите, я прокоментирую. (Я прошу прощения за качество - это мой первый опыт "прицепления"  )
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#6
12.03.2006, 09:00
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Небольшая добавка для практического врача (Nelson)
Approach to Common Causes of Anemia in Children
Is anemia associated with other hematologic abnormalities? • If yes, consider • Aplastic anemia • Leukemia • Other bone marrow replacement disorders Is anemia associated with reticulocytosis? • If yes, usually a consequence of bleeding or ongoing hemolysis Is there associated hyperbilirubinemia or increased serum lactate dehydrogenase • If yes, usually due to hemolysis • Review of peripheral blood smear • Spherocytes (hereditary spherocytosis, autoimmune hemolytic anemia, Wilson disease) • Sickle forms (sickle cell disease, sickle-β-thalassemia) • Target cells (hemoglobin SC disease) • Hypochromic RBC, nucleated RBC (homozygous β-thalassemia, Hgb E-β-thalassemia) • Microangiopathy (hemolytic-uremic syndrome, thrombotic thrombocytopenia • Bite cells/blister cells (G6PD deficiency) Is anemia associated with a lower than appropriate reticulocyte response? • If yes, assess red blood cell size Are red blood cells microcytic? • If yes, usually due to defect in hemoglobin synthesis • Iron deficiency • α or β-Thalassemia trait • Hemoglobin E disorders (AE, EE) • Lead poisons Are red blood cells macrocytic? • If yes, is there neutrophil hypersegmentation (megaloblastic changes)? • If yes, consider • Folate deficiency, vitamin B12 deficiency, inborn errors of metabolism • If no, consider • Diamond-Blackfan anemia • Congenital dyserythropoietic anemia • Pearson syndrome Are red blood cells normocytic? • If yes, consider • Anemia of chronic disease usually (associated comorbid conditions) • Anemia of renal disease (renal failure) • Transient erythroblastopenia of childhood • Anemia associated with hypothyroidism
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#8
12.03.2006, 11:01
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Цитата:
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#10
12.03.2006, 11:36
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ABCLabData - Anemia panel ;Часть 1
Цитата:
• Blood Film • Red Cell Indices • Classification of Anemia • Microcytic Hypochromic Anemia • Normocytic Normochromic Anemia • Macrocytic Anemia ------------------------------------------------- The initial laboratory tests in differentiating causes of anemia are given in the next Table (Wallerstein RO. Consultant. August, 1980. 65-70): Initial Laboratory Tests - Anemia • Hemoglobin, Hematocrit, Red Blood Count • Red Cell Indices (MCHC, MCV, MCH) • Peripheral Blood Film • Reticulocyte Count • Platelet Count • White Cell Count BLOOD FILM: Morphologic alterations, characteristic of certain red blood cell conditions, are given in the next Table: Morphologic Alterations of Red Blood Cells • Spherocytes » Differential Diagnosis : Hereditary Spherocytosis Autoimmune Hemolytic Anemia Acute Alcoholism Hemoglobin C Disease Following Severe Burns Hemolytic Transfusion Reactions Severe Hypophosphatemia Acute Oxidant Injury in Hexose Monophosphate Shunt Defects Clostridium welchii Septicemia • Oval Cells (Elliptocytes) » Differential Diagnosis : Megaloblastic Anemia Myelofibrosis Refractory Normoblasts Anemia Hereditary Elliptocytosis Thalassemia Syndromes • Fragmented Red Cells (Schistocytes) » Differential Diagnosis : Microangiopathic Hemolytic Anemias – Thrombotic Thrombocytopenia Purpura (TTP) – Hemolytic Uremic Syndrome (HUS) – Disseminated Intravascular Coagulopathy (DIC) – Secondary to Immune Mechanisms – Giant Hemangioma – Metastatic Carcinoma – Malignant Hypertension – Eclampsia Macroangiopathic Hemolytic Anemia – Prosthetic Valve Replacement, etc. • Spur Cells (Acanthocytes) » Differential Diagnosis : Abetalipoproteinemia Cirrhosis/Hepatic Necrosis Pyruvate Kinase (PK) Deficiency Uremia Infantile Pyknocytosis • Stippling » Differential Diagnosis : Lead and Arsenic Poisoning Thalassemia Syndromes Sideroblastic Anemia Other Severe Anemias Unstable Hemoglobins Pyrimidine 5'-Nucleotidase Deficiency • Target Cells » Differential Diagnosis : Thalassemias Hemoglobin C, S Liver Disease RED CELL INDICES: Diagnosis, derived from indices, are shown in the next Table: RBC Indices and Anemia • MCV>100 » Diagnosis : Megaloblastic Anemia: Folate or Vitamin B12 • MCV>100 » Diagnosis : Hemolytic Anemia (Elevated Reticulocyte Count) • MCV>100 » Diagnosis : Liver Disease • MCV<80 and MCHC<30 » Diagnosis : Iron Deficiency Anemia or Thalassemia Minor • MCHC>36 » Diagnosis : Hereditary Spherocytosis CLASSIFICATION OF ANEMIA: A classification of anemia is given in the next Table (Cohn LS. Diagnosis. Oct 1983; 125-37): Classification of Anemia • Microcytic Hypochromic Anemia » Index : MCV<80; MCHC<30 • Normocytic Normochromic Anemia » Index : MCV and MCHC Normal • Macrocytic Anemia » Index : MCV>100 Anemia is detected by decreased hemoglobin, hematocrit or erythrocyte count. Anemia is classified as follows: microcytic hypochromic anemia; normocytic normochromic anemia, e.g., hemolytic anemia; and macrocytic anemia. MICROCYTIC HYPOCHROMIC ANEMIA: Microcytic hypochromic anemia is characterized by MCV<80 and MCHC<30; causes are given in the next Table: Causes of Microcytic Hypochromic Anemia • Iron Deficiency Anemia • Thalassemia Syndromes • Defects in Porphyrin Synthesis » Hereditary Sideroblastic Anemia » Acquired Sideroblastic Anemia » Pyridoxine-Responsive Anemia » Lead Poisoning • Severe Protein Deficiency • Chronic Infection Iron Deficiency Anemia: Causes of iron deficiency anemia are given in the next Table: Causes of Iron Deficiency Anemia • Nutritional Iron Deficiency • Chronic Blood Loss, Usually G.I., Uterine, (e.g. Menstrual Blood Loss-Most Common Cause in Women), Hookworm • Achlorhydria and Gastrectomy • Defective Absorption e.g., Sprue or Steatorrhea; Billroth II Procedure for Peptic Ulcer Disease • Increased Demand, e.g. Pregnancy Tests for iron deficiency anemia are given in the next Table: Tests for Iron Deficiency Anemia • Test : Peripheral Smear » Finding : Microcytic, Hypochromic • Test : Red Cell Indices » Finding : Decreased MCV, MCHC • Test : Serum Ferritin » Finding : Decreased • Test : Zinc Protoporphyrin (ZPP) » Finding : Increased • Test : Serum Iron » Finding : Decreased • Test : Serum Iron Binding Capacity » Finding : Increased • Test : Reticulocyte Hemoglobin » Finding : Decreased • Test : Transferrin Receptor » Finding : Increased • Test : Bone Marrow » Finding : Absence of Storage Iron Progressive stages of iron deficiency are as follows: (1) Depletion of Iron Reserves: Bone marrow iron decr; serum ferritin decr; (2) Impaired Erythropoiesis: Serum iron decr; transferrin (total iron binding capacity) incr; transferrin saturation decr; zinc protoporphyrin (ZPP) incr; MCH normal or decr; MCV normal or decr; (3) Anemia: Hemoglobin decr; MCH decr; MCV decr (Finch CA. JAMA 1984; 251:2004).
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#11
12.03.2006, 11:37
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Часть 2
Iron Deficiency Anemia Versus Thalassemia Minor: Thalassemia minor and iron deficiency are both associated with a marked decrease in the MCV. Patients with iron deficiency versus those with beta-thalassemia trait may be differentiated using serum ferritin and MCV (Hershko C. Acta Haematol 1979; 62:236-9) and zinc (erythrocyte) protoporphyrin (ZPP). The characteristics of iron deficiency anemia and thalassemia minor are given in the next Table:
Iron Deficiency Anemia and Thalassemia Minor • Parameter : MCHC (gm/dL) » Iron Deficiency Anemia : <32.5 » Thalassemia Minor : Slightly Reduced • Parameter : MCV (cubic microns) » Iron Deficiency Anemia : <80 » Thalassemia Minor : Usually significantly reduced below 80 • Parameter : MCV/RBC » Iron Deficiency Anemia : >13 » Thalassemia Minor : <13 • Parameter : Serum Ferritin » Iron Deficiency Anemia : Decreased » Thalassemia Minor : Normal • Parameter : Zinc Protoporphyrin (ZPP) » Iron Deficiency Anemia : Increased » Thalassemia Minor : Normal The anemia of thalassemia minor is always mild; hemoglobin is usually between 10 and 13 gm/dL. The red cell count may be higher than normal. The diagnosis is made by finding an elevated HgA2 or HgF on hemoglobin electrophoresis. In iron deficiency anemia, the serum iron is low, serum iron binding capacity is elevated and the serum ferritin is low. There is reduced or no iron in the bone marrow. The MCV/RBC is useful in differentiating iron deficiency anemia and thalassemia minor; MCV/RBC is >13 in iron deficiency anemia but <13 in thalassemia minor. In addition, the zinc protoporphyrin test (ZPP) is normal in thalassemia minor but elevated in iron deficiency anemia; serum ferritin is normal in thalassemia minor but decreased in iron deficiency anemia. Anemia of Chronic Disease: See IRON, SERUM for differential diagnosis of iron deficiency anemia, anemia of chronic disease and chronic renal disease. NORMOCYTIC NORMOCHROMIC ANEMIA: Normocytic, normochromic anemia is characterized by normal MCV (76-99) and normal MCHC (>32). The tests to be considered in normocytic, normochromic anemia are given in the next Table: Tests in Normocytic, Normochromic (Hemolytic) Anemia • Complete Blood Count with Morphology • Reticulocyte Count • Direct Antiglobulin (Coombs) Test • Hemoglobin Electrophoresis • Bone Marrow - If Reticulocyte Count Low • Red Cell Survival • Osmotic Fragility • Bilirubin, Total, Direct and Indirect • LDH and Isoenzymes • Haptoglobin • Urinalysis • Blood Type and Cross-Match • Renal Function Testing The causes of normocytic, normochromic anemia are given in the next Table: Causes of Normocytic, Normochromic Anemia • Sudden Massive Blood Loss • Hemolytic Anemia (Elevated Reticulocyte Count): » Acquired: (Morphologic Abnormalities) – Immune Mediated • Coombs Positive (Autoantibody) • Paroxysmal Nocturnal Hemoglobinuria (PNH) – Microangiopathic • Disseminated Intravascular Coagulopathy (DIC) • Hemolytic-Uremic Syndrome » Congenital: – Defect in Hemoglobin: (Morphologic Abnormalities) • Hemoglobinopathies; Unstable Hemoglobins – Defect of Red Blood Cell Membrane: (Morphologic Abnormalities) • Spherocytosis; Elliptocytosis; Stomatocytosis – Deficiencies of Red Blood Cell Enzymes: (Normal Morphology) • Embden-Myerhof Pathway, Most Common is » Pyruvate Kinase (PK) Deficiency • Pentose Pathway, Most Common is » Glucose-6-Phosphate Dehydrogenase Deficiency • Underproduction (Normal or Low Reticulocyte Count): » Pure Red Cell Aplasia » Drugs » Leukemia » Aplastic Anemia » Myelophthisis » Chronic Disease, e.g. Infection » Renal Failure » Liver Disease (Also Associated with Macrocytosis) » Hypothyroidism (Also Associated with Macrocytosis) Normocytic, normochromic red cells are seen with acute blood loss, hemolysis or bone marrow failure. Reticulocyte Count: The reticulocyte count is useful in differentiating bone marrow failure from other causes of normocytic, normochromic anemia as illustrated in the next Figure: Reticulocyte Count An absolute reticulocyte count is obtained by multiplying the percentage of reticulocytes by the red cell count (Normal reticulocyte count is 25,000 to 75,000 per microliter). Hemolytic Anemia: The usual findings in hemolytic anemia are: reticulocyte count elevated; haptoglobin decreased; serum indirect bilirubin elevated; serum lactic dehydrogenase elevated. Specific tests for hemolytic anemias are given in the next Table: Specific Tests for Hemolytic Anemias • Condition : Autoimmune Hemolytic Anemia » Test : Direct Coombs Test • Condition : Hemoglobinopathy » Test : Hemoglobin Electrophoresis (Hgb S, C, etc.) • Condition : Hereditary Spherocytosis » Test : Osmotic Fragility, Autohemolysis • Condition : Hereditary Nonspherocytic Hemolytic Anemia » Test : Glucose-6-Phosphate Dehydrogenase (G-6-PD) or Pyruvate Kinase (PK) • Condition : Paroxysmal Nocturnal Hemoglobinuria » Test : (see PAROXYSMAL NOCTURNAL HEMOGLOBINURIA SCREEN) Underproduction: Aplastic anemia, myelophthisis and malignancy are associated with bone marrow failure; bone marrow failure is secondary to replacement of normal myeloid tissue as listed in the next Table: Bone Marrow Failure • Condition : Aplastic Anemia » Replacement : Fat • Condition : Myelofibrosis » Replacement : Fibrotic Tissue • Condition : Malignancy » Replacement : Multiple Myeloma, Leukemia or Lymphoma The anemia of chronic disease, infection, inflammation or malignant disease is characterized by low serum iron, low TIBC, normal or increased serum ferritin and normal or increased bone marrow iron stores. Definitive diagnosis of bone marrow failure is made by bone marrow biopsy. Coombs-Positive Hemolytic Anemia: Coombs-positive hemolytic anemia is detected by the direct Coombs test; this test detects antibody or complement on the surface of the red cells. Coombs-positive hemolytic anemias are divided into warm-antibody and cold-agglutinin disease. Warm-antibody disease is generally due to IgG antibody, occasionally complement and sometimes both are present. Some of the causes of warm-antibody disease are given in the next Table: Causes of Warm-Antibody Hemolytic Anemia • Drug-Induced, e.g., Alpha Methyl Dopa, Quinidine, Penicillin • Collagen Vascular Disease • Lymphoproliferative Disorders • Viral Infection • Autoimmune Cold-agglutinin disease is generally due to IgM antibody, but IgM is generally not detected; however, a positive Coombs test is due to complement that remains on the cell surface after IgM has been eluted. This disease is identified by elevated cold agglutinin titer plus a positive Coombs test (see COLD AGGLUTININ TITER). MACROCYTIC ANEMIA: Macrocytic anemia is characterized by MCV>100. The causes of macrocytosis are given in the next Table (Zittoun J, Zittoun R. Semin Hematol 1999; 36:35-46): Causes of Macrocytosis or Macrocytic Anemia • Hematologic Diseases » Folate or Cobalamin Deficiency » Myelodysplastic Syndromes » Aplastic Anemia and Pure Red Cell Aplasia » Leukemia » Multiple Myeloma » Increased Reticulocytosis of Hemolytic Anemia » Increased Reticulocytosis of Folate or Cobalamin – Deficiency after Starting Treatment • Alcohol • Nonhematologic Diseases » Liver disease » Hypothyroidism • Drugs » Cytotoxic drugs (antipyrimidines and antipurines) » Antifolate drugs » Hydroxyurea • Physiological Conditions » Increased neonatal MCV » Pregnancy Folate deficiency is much more common than vitamin B12 deficiency. The laboratory tests to be considered in macrocytic anemia are given in the next Table: Laboratory Aids in Macrocytic Anemia • Screening Tests: » Hematologic Tests: – Red Cell Indices: MCV Increased; MCHC Normal – Blood Counts • Red Cell Count (RBC): Decreased • White Cell Count (WBC): Decreased • Platelets: Decreased – Hemoglobin and Hematocrit: Decreased – Peripheral Blood Smear: Hypersegmentation of the Nuclei of the Polymorphonuclear Leukocytes: Normal segmentation is as follows: Lobes: 2 % of Polymorphs: 20 to 40 Lobes: 3 % of Polymorphs: 40 to 50 Lobes: 4 % of Polymorphs: 15 to 25 There is an average of 3.42 segmentations per 100 cells; in megaloblastic anemia segmentation is increased. Differential diagnosis of hypersegmentation: Megaloblastic anemia; Congenital hypersegmentation;Chronic renal disease. » Chemical Tests: – Lactic Dehydrogenase (LDH): Increased – LDH Isoenzymes: Increase in LDH-1 and LDH-2 – Indirect Bilirubin: Increased (1.0 to 1.5mg/dL) – Serum Iron: Increased » Plasma Volume:Increased • Specific Tests: » Folate, Serum: Decreased in Folic Acid Deficiency » B12: Decreased in Vitamin B12 Deficiency (Approximately 10% False +) • Other Tests in B12 Def.: » Gastrin: Increased » Antibody to Intrinsic Factor: Present in about 2/3 of patients » Achlorhydria: Almost all patients with Pernicious Anemia
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#12
21.04.2006, 23:21
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О нормах. Идиотский вопрос.
Уважаемые коллеги, кто-нибудь знает, с чем связан разброс норм гемоглобина детей? Дело в том, что, согласно приведенной Dr.Ira табличке у годовалого ребенка Нв должен быть в среднем 125 г/л, по рекомендациям ААР - примерно столько же (120 г/л и более), а в имеющемся у меня дома отечественном справочнике "Синдромная диагностика в педиатрии" под редакцией акад. РАМН А.А.Баранова - всего >110 г/л. В разных странах младенцы разные?
 Или у нас на препаратах железа экономят? Просто у моего внешне абсолютно благополучного, на мой взгляд, младенца (1 год 1 мес) в скрининговом анализе Нв 118 г/л. Я в колебаниях - приставать к нему по этому поводу, или пусть живет? Доктор у нас, к сожалению, из породы "грамотных педиатров", так что приходится думать самой.
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#14
22.04.2006, 19:28
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Кончились одобрялки. Добавлю: среднепопуляционно.
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#15
16.10.2007, 10:52
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Мне нужна консультация детского гематолога для моего 7 месячного ребенка. Он родился недоношенным (на 32неделе гестации с весом 1940) в 1 мес гемоглобин был 114г/л, в 2-90, принимали актиферрин, в 3-98, прием актиферина в течении 2 месяцев не улучшил показатели гемоглобина. Был сделан перерыв в приеме лекарств, начали с 4,5 месяцев введение гречневой каши, яблочного и бананового пюре, с 6 месяцев мяса индейки. Сейчас нам 7 месяце и 10 дней гемоглобин 96г/л, эр-3,45, цп-0,83 в течении 10 дней принимаем мальтоферр по 10 капель, 1/4 таб фолиевой к-ты, вит.Д,А,С и сответствующая диета. Что делать дальше? Спасибо за квалифицированную помощь ТСБ.
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Линейный вид
