This document discusses iron deficiency anemia. It begins by providing statistics on iron deficiency from national surveys in the US. The main causes of iron deficiency are then outlined as overt blood loss from conditions like menorrhagia or occult blood loss from the small intestine. Less common causes like reduced absorption or blood loss during pregnancy are also mentioned.
The document then discusses body iron distribution and storage, and the cycling of iron in the body between absorption in the duodenum and storage/utilization in tissues, bone marrow, and the liver. Laboratory tests for diagnosing iron deficiency focus on serum iron, ferritin, and soluble transferrin receptor levels. Treatment involves oral iron supplements, though intravenous iron may be needed if oral
Information about megaloblastic anemia and it's etiology and its classification.
Vitmain b12 deficiencies
Folic acid deficiencies
Signs and symptoms of megaloblastic anemia
Neural tube defects
Information about megaloblastic anemia and it's etiology and its classification.
Vitmain b12 deficiencies
Folic acid deficiencies
Signs and symptoms of megaloblastic anemia
Neural tube defects
Silvio E. Inzucchi, MD, prepared useful Practice Aids pertaining to type 2 diabetes management for this CME activity titled "The Role of SGLT2 Inhibitors in Type 2 Diabetes: CV, Metabolic, and Renal Considerations." For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2l4h3Ss. CME credit will be available until June 27, 2019.
Silvio E. Inzucchi, MD, prepared useful Practice Aids pertaining to type 2 diabetes management for this CME activity titled "The Role of SGLT2 Inhibitors in Type 2 Diabetes: CV, Metabolic, and Renal Considerations." For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2l4h3Ss. CME credit will be available until June 27, 2019.
This is a power point presentation titled "Chronic Stable Angina" . For more medical power points, PDFs, ECGs, X-rays, please visit www.medicaldump.com
Chronic Stable Angina- Diagnosis & management
By Dr Awadhesh Kumar Sharma
Dr. Awadhesh kumar sharma is a young, diligent and dynamic interventional cardiologist. He did his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB Medical college jhansi. Then he did his superspecilisation degree DM in Cardiology from PGIMER & DR Ram Manoher Lohia Hospital Delhi. He had excellent academic record with Gold medal in MBBS,MD and first class in DM.He was also awarded chief ministers medal in 2009 for his academic excellence by former chief minister of UP Smt Mayawati in 2009.He is also receiver of GEMS international award.He had many national & international publications.He is also in editorial board of international journal- Journal of clinical medicine & research(JCMR).He is also active member of reviewer board of many journals.He is also trainee fellow of American college of cardiology. He is currently working in NABH Approved Gracian Superspeciality Hospital Mohali as Consultant Cardiologist.
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This is a power point presentation titled Hypercalcemia of malignancy. For medical power point, x-rays, CT scans, medical projects or other downloads, visit www.medicaldump.com
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
4. Iron deficiency in the United States
National Health and Nutrition Examination Survey (NHANES)
MMWR 51(40); 897-9 Survey of sample US households: ferritin, % saturation, FEP
5. CAUSES OF IRON DEFICIENCY
OVERT BLOOD LOSS
Hematemesis, melena
Severe menorrhagia
Hemoptysis, hematuria, traumatic hemorrhage
OCCULT BLOOD LOSS
Small bowel, vascular, inflammatory
Voluntary blood donations, post-op, iatrogenic
Menses
OBS: delivery, direct iron loss to fetus,
iron loss to the neonate during lactation
6. CAUSES OF IRON DEFICIENCY
UNCOMMON
• Reduced GI absorption of iron: Celiac Disease, Atrophic Gastritis,
H Pylori
• Gastric Bypass for obesity ; Billroth II
• Diet deficient in iron (phytates)
• Intravascular hemolysis — PNH, malfunctioning heart valve
prostheses, Intravascular Hemolysis (Cold Agglutinin)
• Pulmonary Hemosiderosis
• ( IRIDA ) Iron-refractory iron deficiency anemia-- TMPRSS6,DMT1
EMERGING
Response to erythropoietin — Mobilization of iron stores
7. Unexplained iron deficiency:
“Gastrointestinal sideropenia”
• Consider in patients with
relapsed/refractory iron deficiency:
– Celiac disease
– Atrophic body gastritis
– H. pylori infection
– Gastric bypass surgery
8. Body Iron Distribution and Storage
Duodenum Dietary iron
(average, 1 - 2 mg
Utilization Utilization
per day)
Plasma
transferrin
(3 mg)
Bone
Muscle marrow
(myoglobin) Circulating (300 mg)
(300 mg) erythrocytes
Storage
iron (hemoglobin)
(1,800 mg)
Sloughed mucosal cells
Desquamation/Menstruation
Other blood loss
(average, 1 - 2 mg per day) Reticuloendothelial
Liver
(1,000 mg) macrophages
Iron loss (600 mg)
9. Iron Cycling
Erythrocytes
RBC
2500 mg Production
Monocyte-
Macrophage System
Bone Marrow
RBC
Destruction Fe-Transferrin
20 mg
20 mg Daily
Fe-Transferrin Fe-Transferrin
Daily
Plasma Loss
4 mg 1-2 mg
Body Stores
500-1000 mg Daily
5 mg Daily
Fe-Transferrin
Absorption Myoglobin
1-2 mg and Respiratory
Enzymes
Daily
300 mg
Hudson JQ, Comstock TJ. Clin Ther. 2001;23:1637-1671.
Eschbach JW et al. Kidney Int. 1992;42:407-416.
10. Major Iron Compartments
Metabolic
Hemoglobin 1800-2500 mg
Myoglobin 300-500 mg
Storage
Iron storage 0-1000 mg
Transit
Serum iron 3 mg
Total 3000-4000 mg
11. Iron Intake
• Mean iron intake 10-14
mg/d Contribution iron intake 1992-3
to the of food groups
• Historically, main source of to the iron intake 1992-3
iron intake has been meat Other Bread
Other Bread
11%
• Iron intake has stabilized 16%
16% 11%
over the past 25 years Vegetables
Vegetables
16%
• Not a marker of iron status 16%
Cereals
Cereals
• Not a marker of overall Meat
39%
39%
Meat Eggs
nutrition 15% Eggs
15% 3%
3%
Fairweather-Tait S.; Proc Nutrition Society (2004) 63:519-528
12. Effectors of Iron Absorption
• Inhibiting Iron Absorption
– Coffee, tea, milk, cereals, dietary fiber, carbonated
beverages
– Dietary supplements with Ca, Zn, Mn, Cu
– Antacids, H2 blockers, and PPI’s
• Facilitating Iron Absorption
– Vitamin C
– Acidic foods
Alleyne, M. Am J Med. (2008) 121:943-948
16. Laboratory Diagnosis of Iron Deficiency
Soluble Transferrin Receptor (sTfR)
• Transferrin receptor located on surface
of erythroid precursors in bone marrow
• Small amount of transferrin released
into circulation (sTfR)
• Iron deficiency anemia associated with
increased sTfR
17. sTfR: Distinguish Iron Deficiency from
Other Hypoproliferative Anemias
Overall results of sTfR
Sensitivity ~100%
Specificity 69%
Accuracy 88%
18. Neurologic syndromes associated
with iron deficiency
• Pica • Restless leg syndrome
– Definition: Compulsive − Common neurologic
ingestion of a non- disorder
food substance − Criteria for diagnosis:
– Pagophagia Ice eating 1. An urge to move the legs
usually accompanied by
– Occurs in women more uncomfortable sensations
commonly then men 2. Sensation begins or
– Occurs in all causes of worsens during periods of
iron deficiency anemia rest
3. Sensations relieved by
(~25%) movement
4. Worse in the evening/night
− Occurs in ~10% of cases of
iron deficiency anemia
19. Treatment With Iron: Principles
• Ferrous salts are absorbed better than ferric salts
• All ferrous salts are absorbed to the same extent
• Ascorbic acid increases absorption and toxicity
• Iron is absorbed best on an empty stomach; not given
with antacids
• Prescription iron generally better tolerated than iron
salts
• Reticulocytosis occurs <7days; Increase in Hgb 2-3
weeks
• Maximum iron dose ~200 mg/day
20. Available Oral Iron Supplements
Approx. cost
Oral iron Typical Elemental
to give 5000
preparations dose (mg) iron (mg)
mg
Ferrous sulfate 325 mg tid 65 $10.00
Ferrous gluconate 300 mg tid 36 $7-8.00
Ferrous fumarate 100 mg tid 33 $8.00-9.50
Iron
150 mg
polysaccharide 150 $11.00
bid
complex
Carbonyl iron 50 mg tid 50 $18.00
21. Inadequate Response to Oral Iron
Intolerance/Noncompliance (~30%
discontinue)
Persistent blood loss
Decreased iron absorption
Chronic inflammation or bone marrow
damage
Chronic kidney disease
22. Investigati Investigati
onal agent onal agent
Intravenous Iron Preparations (not FDA (not FDA
approved) approved)
Generic name High Molecular Low Ferric Iron Ferumoxtyol Iron Ferric
Wt Iron Dextran Molecular Wt Gluconate Sucrose Isomalto- Carboxy-
Iron Dextran side maltose
Trade name
DEXFERRUM INFeD Ferrlecit Venofer FERAHEME Monofer6 Injectafer
American Regent Watson Watson American AMAG Pharmacosmo American
Manufacturer
Pharmaceuticals Pharmaceuticals Regent Pharmaceuticals s A/S Regent
Carbohydrate High-molecular- Low-molecular- Gluconate Sucrose Polyglucose Isomaltoside Carboxymalt
weight iron dextran weight iron sorbitol ose
dextran carboxymethyl
ether
Molecular weight 265,000 165,000 289,000-440,000 34,000- 750,000 150,000 150,000
measured by 60,000
manufacturer
(Da)
Total-dose or Yes Yes No No No Yes Yes
>500-mg
infusion
Premedication TDI only TDI only No No No No No
Test dose Yes Yes No No No No No
required
Iron 50 50 12.5 20 30 100 30
concentration
(mg/mL)
Black box Yes Yes No No Np NA NA
warning
23. IV Iron Agents are Spheroid Particles with
an Iron Core and Carbohydrate Shell
iron carbohydrate
oxyhydroxide shell
core
Source of core sizes: Kudasheva and Cowman, J Biol Chem
24. IV Iron Agents Differ by
Core Size and Shell Chemistry
Iron Sucrose Ferric Gluconate
bound
bound
sucrose
gluconate
&
weakly
associated
sucrose
core
Kudascheva, J Inorg Biochem. 2004 Nov; 98(11):1757-69
25. Plasma Kinetics of IV Iron Agents:
Ionic Fe+3>SFGC > iron sucrose >> iron dextran
100
% Initial Value Dexferrum®
50
Plasma Iron
Disappearance
INFeD®
Iron sucrose
10 SFGC
Fe+3
0 20 40 60 80
Hours
26. Use of IV Iron Products
18
16
14
Venofer
12
Millions
of Ferrlecit
Units 10
Dexferrum
8
INFeD
6
Total IV
4 Iron
2
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Notes: Ferric gluconate approved February 1999, iron sucrose approved November 2000
Source: IMS Health National Sales Perspectives 1999-2008
28. Percent Hypochromic Red Cells
(%HYPO)
• Flow cytometry with 2 detectors
– High angle for Hb content
– Low angle for cell size
– Allows construction of a histogram for Hb content
Depleted Iron Stores
Intense Erythropoietic
Stimulus, eg ESA
29. Recommended Dosing of IV Iron
Iron Ferric Iron
Ferumoxytol
Sucrose Gluconate Dextran
100 mg/ 2 min
Observe patient for
510 mg/ 17 sec
at least one hour
Observe patient for at
after test dose for
100 mg over 2-5 min 125 mg over signs and symptoms
least 30 minutes after
administration for signs
Push (HDD-CKD)
200 mg over 2-5 min 10 min of anaphylaxis
(Documented iron & symptoms of
(HDD-CKD)
(NDD-CKD) deficiency in whom oral hypersensitivity
adminstration is (CKD)
unsatisfactory or
impossible)
100 mg/100 ml over 15 min
(HDD-CKD)
125 mg/100 1000 mg at 6
Infusion 300 mg/250 ml over 1.5hr
ml over 1 hr mg/min
Not
(0.9% NaCl)
(PDD-CKD)
(HDD-CKD) (Not FDA-approved)
recommended
400 mg/250 ml over 2.5hr
(PDD-CKD)
31. Serious IV Iron Reactions:
Three syndromes
• Anaphylaxis or anaphylactoid reaction
– Sensitivity reaction, marked by allergic manifestations
♦ Hypotension with dyspnea, chest pain, angioedema, or
urticaria
– Immediate, sudden, severe, usually with test dose or 1st
dose
• Labile iron reaction
– Non-allergic, commonly dose-related
• Intolerance reaction
– Presumed sensitivity reaction of any kind, may not be
anaphylactic, preclude further treatment
– Incidence of adverse reactions increases with underlying
autoimmune disease or infection
32. Iron Dextran: Boxed Warning due
to the Risk of Anaphylaxis
IMPORTANT SAFETY INFORMATION
Anaphylactic-type reactions, including fatalities, have followed the parenteral
administration of iron dextran injection.
• Have resuscitation equipment and personnel trained in the detection and
treatment of anaphylactic-type reactions readily available during iron dextran
administration.
• Administer a test dose prior to the first therapeutic dose.
• During all iron dextran administrations, observe for signs or symptoms of
anaphylactic-type reactions. Fatal reactions have followed the test dose of iron
dextran injection and in situations where the test dose was tolerated.
• Use iron dextran only in patients in whom clinical and laboratory investigations
have established an iron deficient state not amenable to oral iron therapy.
33. Incidence of Life-threatening
Adverse Events (Anaphylaxis)
Incidence of
Adverse event
Product (per 106 infusions) Comment
Iron dextran 3.3-11.3 HMW dextran>LMW dextran
Ferric gluconate 0.9
Iron sucrose 0.6
Chertow GM et al Nephrol Dial Transplant 2006;21:378-382
34. Labile iron reactions
• Incidence, severity varies by
– Total dose administered
– Rate of administration
– Iron agent chemical class
• Findings include:
– Cramping, flank pain, chest pain
– Hypotension without allergic manifestations
– Lowering dose or slowing administration
prevents recurrence (not a sensitivity
reaction)
35. Intolerance reactions: Common,
Mild IV Iron Reactions
• Taste disturbance
– “Minty” or “metallic” taste
• Flushing
– Without hypotension
• Like labile iron reaction:
– Transient
– Abate after slowing infusion rate
36. Tolerability of IV iron products
• Hemodialysis patients intolerant to iron
dextran were shown to tolerate ferric
gluconate
• Hemodialysis patients intolerant to iron
dextran or ferric gluconate were able to
tolerate iron sucrose