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aracer.mobi 5. Hoffbrand AV, Moss PAH. Fundamentos da hematologia 6ªed. Porto Alegre: Artmed; 6. Fundamentos de hematologia Francisco Cuellar 6ta edicion aracer.mobi Subido a MEGA Ayudanos compartiendo la pagina y dando like ;). Fundamentos em hematologia, 6ª edição, descreve os princípios básicos em hematologia clínica e laboratorial, apresentando as manifestações de doenças.
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The download Hematologia Fundamentos de Medicina being versionName had taken with Stingers and German ideological financial essays by US when leading against the Russians. In boys, these rates are lower A study conducted in Switzerland with teenagers showed a prevalence of anemia of In other European countries such as Spain, Sweden and England, the prevalence of anemia in adolescents has been reported to be around 4.
In developing countries, the situation is more serious. Population-based studies in which the prevalence of anemia is compared in urban and rural areas show that the percentage of individuals with anemia is much higher in rural areas.
Risk factors for iron deficiency anemia Adolescence is an important period of nutritional vulnerability due to the increased nutritional demands for growth and development during this phase. Iron requirement is high because of intense growth and muscle development, resulting in an increase in blood volume In adolescents, dietary iron intake may be poor as the result of inadequate intake at this particular time of life or the adolescent's diet may have been iron-poor since infancy; however, it is vital that there is an adequate level of iron in the diet with sufficient bioavailability to satisfy the body's demands during this particular time of life Another characteristic that is common among adolescents refers to a change in dietary habits resulting from peer influence, a need for self-affirmation within the family or as the result of the behavioral or social changes that teenagers face during this phase In this context, food also serves as a vehicle that is used to demonstrate feelings of rebelliousness and dissatisfaction, particularly in families in which dialogue is lacking.
In adolescence, eating disorders may include a refusal to eat, excessive weight-loss diets and skipping meals, all because of the undue importance given to body image as a result of inappropriate advertising in the media and the cult of ultrathin, often malnourished models. Another important aspect that should be taken into consideration refers to the consequences of current lifestyles, with increasing dependence on food that can be prepared rapidly and simply.
Fast food is potentially harmful, since there are often important nutritional limitations with this type of food, including its high energy, fat and sodium content in conjunction with its poor fiber, vitamin, calcium and iron content Consequently, adolescents' diets are often based on inadequate socioeconomic and sociocultural values, a distorted body image, poor family eating habits, the financial situation of the family, food consumed outside the home, the availability, ease and speed of food preparation and the influence of peers and of the media.
Most of these factors contribute to an iron-poor diet. Factors that predispose to iron deficiency anemia Iron deficiency anemia is the result of a protracted imbalance between iron intake and demand A great number of factors that predispose to iron deficiency have been mentioned in the literature, particularly early discontinuation of exclusive breastfeeding, lack of iron-rich foods in the diet, frequent tea consumption, prematurity, low birthweight, intrauterine growth restriction, twin pregnancies, perinatal bleeding, socioeconomic level, poor maternal schooling and poor basic sanitation and life conditions2,11,27, The most important factors determinin iron deficiency anemia 1.
An inadequate diet, with poor iron, micronutrient and vitamin content, leading to an insufficient intake of nutrients such as iron, folic acid, vitamin A, vitamin B12 and vitamin D Multiple micronutrient deficiencies are still common worldwide and may be present at any age, hampering both physical and cognitive development The use of medication and food that inhibit iron absorption, including antacids, aspirin, nonsteroidal anti-inflammatory drugs, and excessive phytate, phosphate, oxalate and tannin in-take Overweight and obesity.
Furthermore, overweight and obesity lead to a continuous inflammatory process, intensifying anemia and hampering treatment In this context, these patients also have flattening or atrophy of the intestinal villi, hampering micronutrient absorption34, Another group that merits particular attention consists of adolescent athletes in whom the prevalence of iron deficiency ranges from 5 to 7.
In addition, they are predisposed to developing "sports anemia". This type of anemia appears to be associated with various factors including dilutional pseudoanemia, mechanical intravascular hemolysis and iron loss22,36, Iron deficiency caused by blood loss resulting from injury, accidents or blood donation every ml of blood donated per year results in the loss of another 0.
Iron loss due to parasitosis of the gastrointestinal tract Entamoeba histolytica, Necator americanus, Ascaris lumbricoides, Schistosoma mansoni, Trichuris trichiura 38, esophagitis, angiodysplasia, telangiectasia, atrophic gastritis, colitis, Helicobacter pylori infection, coeliac disease39,40, inflammatory bowel disease, diverticulosis, hemorrhoids, gastrectomy or gastroplasty bariatric surgery , etc.
Genitourinary iron loss of various etiologies46, including paroxysmal nocturnal hemoglobinuria and glomerulonephritis. Pregnancy, childbirth and the use of intrauterine devices.
Menarche and menstrual abnormalities in adolescents, in combination with an inadequate diet.
Heavy menstrual bleeding is also a common cause of iron deficiency and iron deficiency anemia in women of reproductive age. In these cases, menstrual bleeding is moderate, but chronically heavier than normal, causing a negative iron balance47, Iron deficiency anemia is less common in adolescent boys than in girls and this is explained by the physiological increase in hemoglobin levels caused by sexual maturation.
Nonetheless, iron deficiency may be higher in this age group due to blood volume expansion and the increase in muscle mass On the other hand, any increase in hemoglobin levels that might be expected in girls is offset by menstrual blood loss49, Other factors that may increase the risk of anemia and iron deficiency in girls include use of the intrauterine device, pregnancy and also childbirth29, The association between infection and anemia remains controversial; however, the reduction in hemoglobin levels during an infectious process is presumed to be the result of impaired iron release from the reticuloendothelial system and a consequent reduction in the amount of iron available for erythropoiesis Table II lists the most important factors responsible for iron deficiency anemia in adolescents.
The influence of hormones as a cause of anemia in adolescence In adolescence, hemoglobin levels are admittedly higher in males than in females because prostaglandins PGE facilitate erythropoietic activity, both directly PGE 1 and via cyclic AMP PGE 2.
Androgens stimulate erythropoietin action by increasing or facilitating its production in the erythroid stem cells. Conversely, estrogens inhibit the effects of erythropoietin Due to changes in the nutritional requirements of adolescents -at menarche in girls and as a result of the hormonal changes at puberty in boys- hemoglobin levels differ as a function of gender, age or stage of sexual maturity12,53 table I. In women of reproductive age, menstrual bleeding defines anemia, sometimes requiring daily oral iron supplementation.
Women in whom menstrual bleeding is excessive, either with respect to the number of bleeding days or to the amount of flow and the occurrence of menstrual clots, need to be monitored continuously for as long as dysfunctional uterine bleeding is pre-sent47,54, a period in which iron supplementation may indeed be required. The physiopathology of iron deficiency anemia The most important protein as far as iron reserves are concerned is ferritin, which is found in almost all the cells of the body, iron reserves being situated principally in organs such as the spleen, liver and bone marrow33, Serum ferritin level is the most accurate indicator of body iron stores Plasma ferritin levels decrease when there is a deficiency of iron that is not complicated by another concomitant disease.
This reduction in ferritin occurs early, well before the abnormalities in hemoglobin levels, serum iron levels or in erythrocyte size become apparent.
On the other hand, increased ferritin levels may occur in the presence of infections, neoplasms in general, and in cases of leukemia, lymphoma, breast cancer, renal disease, rheumatoid arthritis, hemochromatosis or hemosiderosis, as well as following alcohol consumption Serum ferritin, when used alone as a single parameter, is not considered a good indicator of the nutritional iron status of a population, since this measurement does not provide all the information necessary on the prevalence of anemia27, To reach a definitive diagnosis of iron deficiency anemia, in addition to performing a full blood count hemoglobin, hematocrit, red blood cell count , ferritin and serum iron levels should be measured27, Iron is essential for most living creatures, since it plays a role in numerous vital processes ranging from cell oxidative mechanisms to oxygen transport to the tissues.
Iron homeostasis is regulated principally by iron absorption rather than excretion; therefore, serum iron level reflects the balance between the amount of iron absorbed and the amount used by the body33, Iron deficiency develops gradually and progressively until anemia is established37,39 table III.
The first stage of anemia consists of iron depletion or a negative iron balance. It is characterized by a period of greater vulnerability affecting iron stores and may progress slowly to a more severe deficiency, with functional consequences. The second stage, also referred to as "iron deficiency", is characterized by a phase of erythropoiesis.
Iron is depleted, but anemia is not yet present, although biochemical abnormalities reflect its inability to produce hemoglobin normally. The third stage iron deficiency anemia itself is characterized by a reduction in iron delivery to the bone marrow, reducing both hemoglobin synthesis and content in erythrocyte precursor cells.
The damage inflicted on the body increases as the concentration of available iron diminishes2, Diagnostic approach To diagnose iron deficiency anemia, a full blood count must be performed and serum ferritin levels must be measured37 38 60 When iron is deficient, the body initially turns to its iron stores, consequently depleting them. It is at this stage that ferritin levels fall; however, there are no functional abnormalities at this point.
Next, serum iron levels decrease, transferrin saturation diminishes and iron-binding capacity increases; however, anemia is not yet present. It is only when the negative iron balance persists that anemia develops or manifests it-self29, Diagnosis is based on three different aspects: a complete history of the patient, focusing on possible signs and symptoms; a detailed physical examination, also taking the patient's sexual maturation into consideration; and laboratory tests.
In the majority of cases, the onset of anemia is insidious, with symptoms appearing gradually. The principal symptoms are pallor, fatigue, dyspnea on exertion, tachycardia, palpitations, physical debility, irritability, anorexia, headache, paresthesia, retarded growth, papillary atrophy of the tongue, koilonychia, cheilitis, swollen limbs, changes in appetite, mood changes, attention disorders and poor school performance Less common symptoms associated with anemia include: major hemorrhage resulting from a range of different diseases or injuries that may lead to a state of shock and acute anemia.
Adolescence is a period of profound physical and psychological changes before adult life begins. Therefore, pediatricians should be attentive to a variety of physical, behavioral and social-related facets, in addition to the pathologies that tend to be characteristic of this period of life. Sexual maturity can be staged by evaluating the breasts and pubic hair of girls and the external genitalia and pubic hair of boys. Breasts and male genitals are assessed in accordance with their size, shape and characteristics, while pubic hair is graded according to its characteristics, quantity and distribution tables IV and V.
Stage 1 always corresponds to pre-puberty and stage 5 to the post-pubertal adult phase. Therefore, stages 2, 3 and 4 characterize puberty. This classification system is generally known as the Tanner scale1, Clinical examination of the adolescent patient should take the Tanner scale into consideration tables IV and V , remembering that the iron requirements of the adolescent increase during the pubertal growth spurt Peak growth occurs during Tanner stage 4 when there is extensive formation of muscle mass.
In girls, menarche occurs at Tanner stage 4, a time when growth is already decelerating. During the first years after menarche, menstrual cycles and bleeding are generally irregular due to the immaturity of the hypothalamic-pituitary-adrenal axis, with consequent iron loss The nutritional status of adolescents is important and should be evaluated according to their body mass index BMI and sexual maturation index65 to enable timely identification of any nutritional disorders.
Nutritional status should be evaluated systematically. The initial laboratory workup for anemia consists of a complete blood count and reticulocyte count. When iron deficiency is suspected, total body iron stores should be quantified. Alterations in serum iron levels are only detectable when iron stores have already been depleted.
Total iron-binding capacity and free erythrocyte protoporphyrin are above normal in the presence of iron deficiency67, Nevertheless, in infectious, inflammatory or malignant states, ferritin levels may be high, since it is an acute-phase reactant67, Therefore, although all these tests are useful, no single test is acceptable alone for a diagnosis of iron deficiency and, whenever possible, ferritin measurement should be given priority among the iron store markers.
Various other tests may help lead to a diagnosis of anemia, including iron-binding capacity, transferrin saturation, free erythrocyte protoporphyrin, transferrin receptors and also bone marrow testing, which, although useful for establishing a diagnosis of iron deficiency anemia, is only used when diagnosis proves difficult and all other methods have already been attempted70, Evaluation of the gastrointestinal tract in patients with iron deficiency anemia Evaluation of the gastrointestinal tract forms an integral and obligatory part of the investigation of any patient of any age with iron deficiency anemia.
The principal tests used to investigate the digestive tract are a fecal occult blood test, upper gastrointestinal endoscopy and colonoscopy. In the case of patients whose results are normal in all of these tests, others such as labeled erythrocyte scintigraphy, angiography and capsule endoscopy may be performed5,8, It is important to bear in mind that iron refractory iron deficiency anemia may occur as a symptom of coeliac disease.
It should also be remembered that anemia may occur in patients with gastroesophageal reflux disease, in food allergies and in inflammatory bowel disease.
Although the finding of upper digestive tract abnormalities at endoscopy is common and includes esophagitis, gastritis and hiatus hernia, in many cases, these conditions do not, on their own, explain the presence of iron deficiency.
On the other hand, colonoscopy may reveal infectious or inflammatory processes, polyps or neoplastic causes8. Differential diagnosis of microcytic anemia The most important differential diagnosis in patients with iron deficiency anemia is beta-thalassemia minor.
When thalassemia minor is associated with iron deficiency anemia, HbA2 measurement is affected and levels are lower. Therefore, if this association is suspected, total body iron stores should be corrected prior to measuring HbA2.
Another differential diagnosis for iron deficiency anemia is anemia of chronic disease. In general, this type of anemia is asymptomatic or oligosymptomatic and is associated with the presence of an inflammatory or infectious disease or with neoplasia. Usually, it is a normochromic and normocytic form of anemia; however, it may be microcytic and hypochromic.
Serum iron levels and transferrin saturation are low; nevertheless, ferritin is normal or elevated, with normal or high levels of iron in bone marrow5,11,31, Prevention of iron deficiency anemia should be based on four approaches: 1.
Nutritional counseling aimed at improving the quality of the diet. Breastfeeding should be encouraged; 2. Iron supplementation therapy; 3. Fortification of food; 4. Infection control. Providing dietary counseling is fundamental and it is important to explain that the bioavailability of iron obtained from meat red or white meat is greater.
In addition to meat, individuals should be encouraged to consume citric fruits, vegetables and legumes and be warned to avoid sodas, tea, coffee, excessive amounts of milk, and cereals that reduce iron absorption Primary prevention of iron deficiency in adolescents is not recommended.
Some investigators defend the prescription of iron supplements to adolescents as secondary prevention due to the high prevalence of iron deficiency in this population, particularly in girls69 and in athletic teenagers. The American Academy of Pediatrics recommends that adolescent girls should be followed up annually after menarche and boys should be monitored during their growth spurt to identify anemia. In Brazil, the Ministry of Health decreed that all wheat and corn flour produced from July onwards should be supplemented with iron Other foods such as milk are also fortified with iron, which helps to prevent anemia Adolescents in these categories should be screened and a full blood count and ferritin measurement should be performed73, Treatment Forms of iron supplementation and its benefits Iron deficiency and its many consequences can be corrected simply, cheaply and effectively.
The most common approach is to provide iron supplements to pregnant and breastfeeding women and to breastfeeding infants within a primary healthcare program. Despite the confirmed efficacy of these programs, their effectiveness is sometimes very low.
The principal objective of dietary interventions is to increase the body's iron stores Supplementation therapy Iron supplements should be prescribed to all patients with a diagnosis of anemia, since dietary changes alone are unable to correct iron deficiency anemia. Oral supplementation is the modality of choice, with parenteral administration being reserved for patients unable to tolerate oral supplements Iron salts ferrous sulfate, fumarate and gluconate are highly bioavailable, rapidly absorbed and inexpensive.
Since absorption of these salts is hampered by food, they should be taken one hour before meals. On the other hand, they may provoke gastrointestinal side effects such as diarrhea, epigastric pain, nausea and constipation Therapies with ferrous salts and iron chelates are effective and cause few side effects.
Furthermore, their absorption is unaffected by food; therefore, they can be taken either fasting or during meals. Their major drawback is cost. The treatment dose depends on the severity of the anemia. For adolescents and adults, the dose is 60 mg of elemental iron twice a day in the case of moderate anemia Treatment should result in an increase in hemoglobin levels of 1.
After hemoglobin levels return to normal, treatment should be maintained using the same dose for at least weeks so as to replenish the body's iron stores Blood transfusions are rarely required and are restricted to severe cases in which there is a significant loss of blood and a risk of cardiac decompensation Iron-fortified foods are important and several studies have been published showing their effectiveness77, Controlling infections is important, since iron is also reduced in chronic diseases and this may result in an erroneous diagnosis of iron deficiency anemia.
Gastrointestinal and respiratory tract infections are known to predispose to a depletion of iron stores in the body due to diminished hemoglobin production and iron absorption70, Conclusion In view of the magnitude of this problem and the number of risk factors involved, urgent and systematic measures need to be taken to prevent and treat iron deficiency anemia in adolescents.
Iron deficiency anemia is common worldwide. Fortifying food with iron is the most effective measure for combatting iron deficiency in a population, since this strategy extends to all socioeconomic groups. The use of fortified milk formulas has contributed towards a decline in iron deficiency in infants of various countries.
In Brazil, the most extensive experience has been with the use of fortified milk, in powdered or liquid form, with results that have proven satisfactory both for the prevention and treatment of anemia77, Iron deficiency anemia remains a major public health issue in Brazil despite all the knowledge available on intervention measures.
Various research studies have published excellent results with the establishment of preventive measures or treatment such as iron-fortified foods and iron supplements, measures that should always be implemented in conjunction with dietary counseling20, The ideal strategy is to treat prophylactically and to recognize those individuals at risk of developing anemia as early as possible to prevent onset of the disease and its complications.
Therefore, educating healthcare professionals to implement preventive strategies, to treat infections and to detect iron deficiency and anemia at an early stage is vital Few population-based studies have been conducted in Brazil specifically on iron deficiency anemia in adolescents; therefore, there is a need for a greater in-depth analysis of dietary habits and anemia in this age group in the different geographical regions of the country. References 1. Prevalence of iron-deficiency anemia in Brazil: a systematic review.
Rev Paul Pediatr ; 27 1 : Braga JAP. O papel do ferro no crescimento e desenvolvimento infantil.
O papel dos micronutrientes no crescimento e desenvolvimento infantil. World Health Organization.
Iron deficiency, anaemia assessment, prevention, and control. A guide for programme managers. Geneva;