Anemia literally means "Lack of Blood". However, it actually refers to reduction in the capacity of Blood to carry oxygen to various body parts. It can be due to reduced number/poor quality of Red Blood cells or Lack of Oxygen carrying chemical present in Red Blood Cells namely, Hemoglobin.
WHO criteria for diagnosis of Anemia are Hemoglobin <13gm/dL in adult males and <11gm/dL in adult females.
Signs and Symptoms of Anemia include Pale skin, feelings of weakness or fatigue, poor concentration, shortness of breath, inflammed tongue (glossitis), Spoon nails, Restless leg syndrome, Fatigue, Irritability and Pica -A craving for peculiar substances such as soil or clay.
As discussed previously, anemia is related to RBCs and Hemoglobin. Though the simplest cells in the body, the main function of the RBCs is creation and maintenance of physical integrity and functionality of hemoglobin, an oxygen carrying molecule. Numerous substances are necessary for creation of RBC & Hemoglobin, including metals (iron, cobalt, manganese), vitamins (B12, B6, C, E, folate, riboflavin, pantothenic acid, thiamin), and amino acids. Regulatory substances necessary for normal erythropoiesis include certain chemical substances known as hormones like erythropoietin, thyroid hormones, and androgens.
Thus, any condition that involves deficiency of involved substances or excess destruction of RBCs may lead to anemia. Various conditions leading to anemia include Heavy periods, Pregnancy, Ulcers, Colon polyps or colon cancer, genetic disorders, a diet that does not have enough iron, folic acid or vitamin B12 [Iron, vitamin B12, and folic acid are three of the most important substances for RBC & Hemoglobin production], Blood disorders [sickle cell anemia and thalassemia, or cancer], Aplastic anemia [inherited or acquired] and G6PD deficiency, a metabolic disorder.
Anemia is typically diagnosed on a Complete Blood Count and the Hemoglobin Level. Examination of a stained blood smear [known as Peripheral Smear or P/S] using a microscope can also be helpful. Usually in labs, four parameters (RBC count, hemoglobin concentration, MCV and RDW) are measured, allowing others (hematocrit, MCH and MCHC) to be calculated.
Usually, anemia is classified by the size of red blood cells which are assessed both by automatic analyzers as well as by Peripheral Smear examination. The size is reflected in the mean corpuscular volume (MCV). If the cells are smaller than normal (under 80 fl), the anemia is said to be microcytic; if they are normal size (80–110 fl), normocytic; and if they are larger than normal (over 100 fl), the anemia is classified as macrocytic. This scheme quickly exposes some of the most common causes of anemia; for instance, a microcytic anemia is often the result of iron deficiency and macrocytic anemia is usually due to deficiency of Vitamin B12 or Folic acid. Normocytic anemia is usually due to more sinister causes like conditions leading to chronic blood loss like heavy periods, ulcers, cancers or due to reduced RBC production like Aplastic Anemia/Myelofibrosis.
Thus, after classifying the anemia certain specialized tests can be ordered depending on the type of anemia like Serum Iron and Ferritin levels as well as Total Iron Binding Capacity to assess for Iron deficiency, direct estimation of Vitamin B12 and Folate levels as well as Intrinsic Factor or Stool for Occult blood and bone marrow studies for assessment of normocytic anemias.
Treatment of Anemia depends on severity and cause. First, the underlying cause of the anemia should be identified and corrected. For example, anemia as a result of blood loss from a stomach ulcer should begin with medications to heal the ulcer. Likewise, surgery is often necessary to remove a colon cancer that is causing chronic blood loss and anemia.
Oral or Parenteral Iron supplements will also be needed to correct iron deficiency. In severe anemia, blood transfusions may also be necessary. Vitamin B12 injections and Folate therapy are needed for patients suffering from pernicious anemia or other causes of B12 deficiency.
In certain patients with bone marrow disease or patients with kidney failure, Erythropoeitin injections as also repeated blood transfusions may be required as therapy.
Polycystic Ovarian Syndrome or PCOS/PCOD as the name signifies is actually a problem in Females associated with Ovarian dysfunction leading to various abnormalities like Excess Hair Growth, Obesity, Severe Acne, Menstrual Irregularity, Infertility etc.
Usually, the ovarian function is regulated by a complex interplay of certain chemicals known as Hormones which are usually present in the blood in minute quantities and initiate/catalyse various processes for proper ovarian functioning. Any disbalance in this delicate process may lead to abnormal ovarian function and lack of egg development leading to various clinical problems encountered.
Various hormones that are involved in the process include:
a) Female Hormones i.e. FSH [Follicle Stimulating Hormone], LH [Leutinizing Hormone]
b) Male Hormones [also found normally in miniscule amount in female bodies] i.e. DHEA & Testosterone
c) Female Hormones like 17-Hydroxyprogesterone & 21-Hydroxylase
d) Thyroid Hormones i.e. T3, T4, TSH [Thyroid Stimulating Hormone]
e) Lactational Hormone i.e. Prolactin
In addition to clinical abnormalities encountered, certain other diseases have been found to be associated with PCOS/PCOD leading to further problems in the patients. Various diseases associated with PCOD are:
a) Pre Diabetes/Diabetes: PCOD has been shown to have definite association with Insulin Resistance [Hormone for maintaining Glucose levels in the body] with a High Risk for Diabetes and its various complications.
b) Obesity: Obesity and High Cholesterol levels are also constantly associated with PCOD.
As discussed above, the diagnostic tests for PCOS aim to evaluate for various Hormonal levels and their abnormalities to determine the cause and treat accordingly with few tests being meant to assess for associated Diseases which are to be managed along with. Thus, the various tests that can be done are:
a) FSH & LH: Increased LH levels & normal or slightly reduced FSH levels with LH/FSH ratio of >3:1 in first half of menstrual cycle in indicative but not confirmatory of PCOS. However in few Patients, there may be normal FSH: LH ratio.
b) Testosterone levels: Total testosterone levels are more reliable. Levels are usually normal or slightly reduced in PCOS. Levels > 200ng/dL warrant further investigation to rule out Ovarian/Adrenal Tumor.
c) DHEA-S levels: Levels > 800µg/dL warrant further investigation to rule out Adrenal Tumor.
d) Prolactin: Patients with PCOS usually have mild and transient Prolactin elevation. Persistent elevation requires further investigations to rule out Pituitary tumor [Prolactinoma].
e) 17-Hydroxyprogesterone: A fasting, unstimulated level of < 200ng/dL is normal. A level > 200ng/dL requires post ACTH stimulation values for confirmation of 21-Hydroxylase deficiency.
f) 24 Hour Urine Cortisol levels may also be prescribed to rule out Cushing's Syndrome
g) Serum Cholesterol Levels: Are important for assessment of associated Cardiac risks due to Obesity.
h) Glucose Tolerance Test & Fasting Glucose/Insulin Ratio: Impaired Glucose Tolerance & Fasting Glucose/Insulin ratio < 4.5 are diagnostic of Insulin Resistance.
USG may show increased size, increased stroma and multiple small peripheral follicles. However, USG may be normal in 30-50% cases of PCOS/PCOD.
Oral Contraceptives are mainstay of treatment along with Metformin & Weight Loss/Lifestyle modification to reduce Insulin Resistance, Cosmetic procedures & Antiandrogens like Spironolactone to counteract the effect of Male Hormones like Hirsutism; and Clomiphene Citrate & Thiazolididiones to treat associated Infertility by increasing Egg production and development.
What is Vitamin D?
Vitamin D is one in the group of multiple chemicals required by the body in very small quantities serving as intermediaries in various important processes in the body vital for normal functioning and development. Vitamin D is a fat-soluble vitamin. This means that it is stored in our fat cells for use when it is needed.
What are the sources of Vitamin D?
Vitamin D has two biological forms. Vitamin D2 (D2), also known as ergocalciferol, is obtained from dietary vegetable sources and oral supplements. Vitamin D3 (D3), also known as cholecalciferol, is obtained primarily from skin exposure to ultraviolet B (UVB) radiation in sunlight, various foods such as oily fish, fortified foods (milk, juices, margarines, yogurts, cereals, and soy), and oral supplements. Aside from rich sources such as oily fish, the vitamin D content of most foods is between 50 and 200 IU per serving.
What are the functions of Vitamin D?
Traditionally, Vitamin D is considered to have essential role in calcium metabolism and bone remodeling/ strengthening. However, recently many other important processes other than these have been attributed to it. Various benefits associated with adequate vitamin D levels are:
• Prevention of osteoporosis and osteopenia
• Lowering blood pressure in people with hypertension
• Lowering incidence and severity of cardiovascular disorders
• Reduced risk of Type 2 diabetes
• Decreased inflammation and Reduced risk of allergies
• Decreasing dental cavities
• Prevention and treatment of depression as well as mental diseases like Schizophrenia
• Regulating cholesterol levels in the blood
• Decreasing mortality rate from certain cancers like colon, breast, ovarian, melanoma, and prostate cancer
What are the Causes of Vitamin D Deficiency?
An estimated 1 billion people are deficient or insufficient in vitamin D. Almost 25-50% of routine patients encountered in clinical practice have Vitamin D deficiency. The causes for Vitamin D deficiency include improper exposure to Sunlight, Darker Skin, Obesity, Malabsorption diseases and Increasing Age. In addition, a wide variety of medications, including antifungal medications, anticonvulsants, glucocorticoids, and medications to treat AIDS/HIV can enhance the breakdown of vitamin D and lead to low levels. There is also a loss of vitamin D for those with chronic kidney disease, primary hyperparathyroidism, chronic granuloma-forming disorders, and some lymphomas.
How to Assess Vitamin D Deficiency?
Vitamin D deficiency is usually accompanied by normal blood levels for calcium and phosphorus, high-normal or elevated levels of PTH, normal to elevated levels of total alkaline phosphatase, a low 24-hour urine calcium excretion rate, and low levels of total 25(OH)D.
Measurement of the total 25(OH) D level is the best test to assess body stores of vitamin D. The total 25(OH) D level allows for the diagnosis and monitoring of vitamin D deficiency, whereas quantification of 25(OH) D2 and 25(OH)D3 fractions may facilitate treatment monitoring.
The guidelines for serum (blood) 25(OH) D levels are as follows:
• Deficiency: 25(OH)D level below 12 ng/mL
• Inadequate/Insufficient: 25(OH)D level between 12-20 ng/mL
• An adequate 25(OH)D level is between 20-50 ng/mL
• Excessive: 25(OH)D level over 50 ng/mL
HOW TO PREVENT AND TREAT VITAMIN D DEFICIENCY?
Many patients and physicians think that adequate vitamin D intake can be obtained via diet alone. This assumption is erroneous. With the exception of fatty fish, the vitamin D content of most foods, including fortified dairy products, is relatively low to nonexistent.
Vitamin D supplementation is safe and inexpensive, but vitamin D deficiency often remains undiagnosed or is undertreated. The amount of vitamin D that is needed to correct a deficiency will depend on the severity of the deficiency. When the blood level is below 30 ng/mL, a minimum of 1,000 IU/day of vitamin D3 will be needed for children and 1,500 to 2,000 IU/day of vitamin D3 for adults. Another rule of thumb is for every 1 ng/mL increase in your blood level you need an additional 100 IU/vitamin D per day.
Getting about 10 to 15 minutes of sun exposure a couple of times per week can also help in Vitamin D synthesis in many people.
Diabetes refers to a group of conditions which affects how Glucose, main source of energy in our body, is utilized. In Diabetes, usually glucose is underutilized and overproduced, causing Increased Blood levels of Sugar leading to various symptoms and complications. A hormone predominantly secreted by Pancreas, known as Insulin, plays central role in this metabolism. The disease is classified into various categories, most common being Type 1 or IDDM, Type 2 or NIDDM [accounts for 85-95% cases] and Gestational Diabetes [during Pregnancy
Risk Factors and Clinical Symptoms
Various factors that are associated with increased risk for Diabetes include increased weight, reduced activity, Family History of Diabetes, Polycystic Ovarian Syndrome, High Blood Pressure, Low levels of HDL Cholesterol [<35mg/dL] and High Triglyceride levels [>250mg/dL].
Some people, especially those with prediabetes or type 2 diabetes, may not experience symptoms initially. In type 1 diabetes, symptoms tend to come on quickly and be more severe. Some of the signs and symptoms of type 1 and type 2 diabetes include increased thirst and frequent urination, unexplained weight loss, frequent change in visual acuity and blurred vision, Slow healing/ non healing ulcers and frequent Infections.
In Medical parlance, Diabetes and High Blood Pressure are known as "Silent Killers", as long-term complications of both develop gradually and involve almost all body organs especially cardiovascular, nervous and Renal System. Moreover, the risk of complications is directly related to duration of disease as well as extent of hyperglycemia. Eventually, diabetes complications may be disabling or even life-threatening. Possible complications include Cardiovascular disease, Nerve damage (neuropathy), Kidney damage (nephropathy), Eye damage (retinopathy), Foot damage [due to Nerve damage or poor blood flow to the feet], fungal infections of skin and gum, reduced bone mineral density and Alzheimer's disease.
Usually, three main tests are used to diagnose/follow up the suspected diabetic patients. These include Blood Sugar Fasting/Post Prandial, Glucose Tolerance Test and Glycosylated Hemoglobin/HbA1c. Few other tests are also done to assess for associated risk factors/complicaitons of Diabetes.
Presently, the criteria used for diagnosis of Diabetes based on Blood Glucose levels are 1) an Fasting Blood Glucose value ≥ 126 mg/dL; 2) a 2-hour Postprandial glucose concentration ≥ 200 mg/dL; or 3) symptoms of diabetes and a Random (i.e., regardless of the time of the preceding meal) Blood glucose concentration ≥ 200 mg/dL.
However, these tests measure glucose levels only in the short term and give variable results during stress and illness. Standardized hemoglobin A1c (HbA1c) assays reliably estimate average glucose levels over a longer term (approximately 10-12 weeks), do not require fasting or glucose consumption, have less variability during stress and illness, and are more specific for identifying individuals at increased risk for diabetes. Therefore, HbA1c is recommended as an additional alternative for diagnosing diabetes and increased diabetes risk. Values > 6.5% are clinically significant. Moreover, the long-term HbA1c measure is also recommended to be used as the primary test of glycemic control in all non-pregnant adults with diabetes; as lowering HbA1c levels by 1% reduces the risk of microvascular complications by approximately 40%. Other important tests to assess for various Diabetic complications are Routine eye and foot exams, along with blood pressure, Lipid profile, Urine routine examination as well as urine microalbumin levels, and Renal Function tests [Bl. Urea, S. Creatinine, S Electrolytes etc.].