Blood And Nutrition

Question 1

Blood

Answer 1

Made up of cells and plasma
Cells = RBC, platelets and WBCs
Blood transports; gas, nutrients, waste and hormones
Regulates pH, temperature, water and electrolytes
Protects against disease (via immune cells) and blood loss (via clotting)

Question 2

White blood cells

Answer 2

Split into; monocytes, lymphocytes and granulocytes
Lymphocytes split into T and B cells
Granulocytes split into; eosinophils, neutrophils and basophils

Question 3

Haematology

Answer 3

Study of blood

Question 4

Different types of anaemia

Answer 4

Iron deficiency anaemia
Sickle cell anaemia
Megaloblastic anaemia
Haemolytic anaemia
Renal anemia
Must determine the type before beginning treatment as iron stalls can be harmful can lead to iron overload in those who dont need them

Question 5

Iron deficient anemia

Answer 5

Caused by lack of iron
Iron is needed to make haemoglobin
Only give iron when justified - in this case lack of iron = need iron
Can be used as prophylaxis only; malabsorption diseases (chrons), menorrhagia, pregnancy, total gastrrectomy, haemodyalsis (chronic renal failure), management of low birth weight infant

Question 6

Characteristics of iron deficiency anaemia

Answer 6

Small (microcytic) and pale (hypochromic) Red blood cells

Question 7

Symptoms of iron deficiency anaemia?

Answer 7

Tiredness
Struggling to concentrate at work or colleague
Memory problems
Reduced ability to exercise
Hair loss
Dyspnoea
Brittle nails or change shape (ridigid, concave, break easily, spoon shaped)
Cuts and grazes take longer to heal
Sore tongue
Sores at the corner of the mouth

Question 8

What causes iron deficiency anaemia?

Answer 8

Causes; dietary deficiency, malabsorption, increased blood loss, increased requirements
Drug induced antiplatelet, anticoagulants, NSAIDs, SSRIs and corticosteroid

Question 9

Oral iron

Answer 9

Little differences between iron salt in efficiency and absorption of iron
Choice determined by cost and side effects
Oral dose of elemental iron for iron deficiency anaemia should be 100 - 200 mg daily
Ferrous sulphate (normal and dried), ferrous fumorate, ferrous gluconate
Ferrous sulphate and fumeroate are populate as small amount contains high contents of iron

Question 10

Iron important facts and figures

Answer 10

He concentration should rise by about 100-200 mg / 100 mL per day daily
20g/L over 3-4 weeks
When haemoglobin has reached normal ranges, continue for 3 months or replenish iron stores
Ascorbic acid (vitamin C) aids absorbtion

Question 11

How to treat iron overload

Answer 11

Desferrioxamine

Question 12

Side effects of iron

Answer 12

Constipation or diarrhoea
MR iron can exacerbate diarrhoea in certain patients e.g IBS
GI discomfort, nausea
Care with patients with intestinal strictures and diverticular disease

Question 13

Counselling on iron

Answer 13

Best absorbed on an empty stomach
Vitamin C (ascorbic acid) aids absorption
Can be taken after food to reduced S/E of GI if needed
May discolour stool

Question 14

Parenteral iron

Answer 14

MHRA; hypersensitivity reaction; including life threatening and fatal anaphylactic reaction
Avoid I.V iron in 1st trimester of pregnancy, only is in second or third if benefits outweighs risk
Only use when oral is ineffective
Compound preparations; folic acid + iron only for pregnant women at high risk of iron and folic deficiency

Question 15

G6PD deficiency

Answer 15

Predisposed to haemolytic anaemia
Genetic condition in which RBCs break down when the body is exposed to certain drugs or stress/infection (hereditary) or fava beans (broad beans)
Prevalent in Africans, Asians, Oceania and south Europe
More common in men than women
Drugs found safe in one G6PD deficient patient may not be safe in another
Manufactures don’t routinely test their drugs on this sets of patients
Risk and severity of haemolytic is dose related

Question 16

Definite risk of haemolysis in G6PD.

Answer 16

Nitrofurantoin
Quinolones
Dapsone
Methylthioninium chloride
Sulfone
Sulfonamides

Question 17

Possible risk of haemolysis in G6PD deficienct

Answer 17

Aspirin
Chloroquine
Menadione
Quinine
Sulfonylureas

Question 18

Megaloblastic anaemia

Answer 18

Vitamin B12 and folate is common cause
Caused by; poor diet, pregnancy, methotrexate and antiepileptics
Characteristics; larger than normal RBCs (macrocytosis)
Pernicious anaemia (malabsorptions and vitamin B12; due to lack intrinsic factor) common cause
Hydroxocoblamin, diet related, cynocobalamin
Treat folic acid for 4 months as well to replenish stores; don’t give only folic as it will mask B12 deficiency symptoms

Question 19

Folic acid

Answer 19

Given alone or in Megaloblastic anaemia (for neuropathy)
Given in folate deficiency Megaloblastic anaemia as well as prophylaxis
Taken before and during pregnancy to prevent neural tube defects
High risk; 5 mg
Low risk 400 mcg

Question 20

Folinic acid

Answer 20

Given as calcium folate
Effective in treatment of folate deficiency Megaloblastic anaemia but generally used with cytotoxic

Question 21

Hydroxocabalamin

Answer 21

Vitamin B12
Replaced by cyanocobalamin in form of vitamin B12 of choice
Retained in the body for longer therefore is better

Question 22

Sickle cell disease

Answer 22

Structurally abnormality of Haemoglobin leading to deformed, less flexible RBCs
Causes reduced oxygen to organs and severe pain
Sickle cell crisis requires hospitalisation, IV fluids, analgesia and treatment of concurrent infections
Increases susceptibility to infection and various vaccines required and prophylactic penicillin
Chronic complications include skin ulcerations, renal failure and increased infection risk
Take folic acid throughout pregnancy 5 mg

Question 23

Acute porphyria

Answer 23

Hereditary disorder of haem biosynthesis
Prevalence abour 1 in 75000 of the population
Certain drugs can induce acute prophetic crises
Screen relatives and advice dangers of certain drugs
TREATMENT; Haem arginate IV infusion
Signs and symptoms; severe abdominal pain, pain chest, legs, back, N/V, red/brown urine, muscle pain, numbness, tingling
Unsafe to use; MAOIs, TCA, anabolic steroids, contraceptions, antifungals, HRT, barbiturates, seek specialist advice

Question 24

Haemolytic anaemia

Answer 24

E.g Sickle cell and thalassaemia
RBCs die or are destroyed early in their life and are unable to replace RBC that have been destroyed quickly enough
Aim to treat underlying cause to decrease RBC destruction

Question 25

How to treat erythropoietin deficiency in CKD

Answer 25

Epoetins treat anemia

Question 26

Hypoplastic and haemolytic anaemia treatment

Answer 26

Anabolic steroids Corticosteoids Puridoxiine Anti lymphocytes immunoglobulin Rituximab

Question 27

Phenylketonuria

Answer 27

Inability to metabolise phenylalanine Managed by restricting dietary intake of phenylalanine Aspartame contributes to phenylalanine intake (inform patients of aspartame contains products) Symptoms; moldy musty smell to breath and skin, tremors, Brian damage, eczema, behavioural difficulties, repeated being sick

Question 28

Total parenteral nutrition

Answer 28

TPN Sole source of nutrition Glucose is given via central vein to avoid thrombosis (add enough phosphate to allow phosphorylation) Fructose and sorbitol added to avoid hyper o solar hyperglycaemia non ketoacidosis acidosis Used; chemotherapy, radiation therapy, major surgery, prolonged GI disorders, coma, refusal to eat, under malnourished Contains amino acids, glucose, fat, electrolytes, trace elements, vitamins E.g nutriflex

Question 29

Special diet

Answer 29

Preparations which have been modified to eliminate a particular constituent from a food E.g gluten free

Question 30

Neural tube defects

Answer 30

Congenital defects caused by incomplete closure of neural tube within 28 days of conception E.g spina birdies, encephalocole and anencephaly Main risk factors; maternal folate deficiency or B12, previous Hx of baby with neural tube defect, smoking, obesity, diabetes, use of anti-epileptics, older patients at higher risk Supplement with folic acid before and 12 weeks into pregnancy unless high risk

Question 31

High risk patients with neural tube defect babies

Answer 31

Sick cell Thalassemia Previous history Diabetic Anatiepileptic drugs Obsess >30 kg/m2

Question 32

Folic acid and neural tube defect

Answer 32

Low risk; 400 mcg before and 12 weeks of pregnancy High risk; 5 mg before and up to 12 weeks Sickle cell and thalassaemia take throughout pregnancy

Question 33

Magnesium

Answer 33

PPIs can decrease magnesium concentration = HYPOmagnesium Involved energy generation Higher doses cause diarrhoea e.g antacids high concentration Can cause lead to imbalances with calcium, proassium and sodium Treat magnesium sulphate Normal range 0.7 to 1.05

Question 34

Zinc deficiency

Answer 34

Only give supplements if deficient and evidence seen Deficient in; diet, malabsorption, trauma, burns Treat Wilson’s disease (rare condition that reduces zinc absorption)

Question 35

Oral rehydration therapy

Answer 35

Enhances absorption of water and sodium Replaces electrolytes safely Prevents possible induction of osmotic diarrhoea Palatable (different flavours available), child friendly and readily available E.g dioralyte

Question 36

HYPERkalaemia

Answer 36

> 5.5 mmol/Mol Signs and symptoms; ventricular tachycardia/fibrillation, peak T waves, cardiac arrest Cause/factors; Addisons disease, CKD, ketoacidosis, ACEi/ARBs, NSAID, heparin, Ciclosporin, spironolactone, epelorone, digoxin Treatment; calcium gluconate 10% IV, soluble insulin, salbutamol Review and stop drugs which exacerbate Monitoring; serum potassium, blood glucose, ECG Any ECG change is regarded as severe hyperkalaemia

Question 37

HYPOkalaemia

Answer 37

<3.5 mmol/Mol Signs; mild can be asymptomatic, moderate; lack energy, constipation/muscle pain, severe muscle weakness, respiratory failure, paralysis and paraesthesia Causes; diarrhoea, vomiting, alcohol cirrhosis, diuretics (K sparing) Treatment; check if drug induced and withhold, depending on severity; supplement K (banana etc), oral supplements or IV pottasium Exacerbates digoxin toxicity

Question 38

Phosphorus

Answer 38

Oral phosphate supplements and vitamin D required in small numbers with hypophosphataemic vitamin D resistant rickets Phosphate infusions used alcohol dependence Phosphate depletion occurs in severe ketoacidosis Sevelamar and lanthanum liecensed for treatment of hyperphosphataemia (patients on haemodyalsis and pernotreal dialysis)

Question 39

HYPERnatraemia

Answer 39

High sodium 146 + Symptoms; convulsions, dehydration, thirst, hypokalaemia, tachycardia Causes oral contraception, corticosteroids, lithium, sodium bicarbonate, high sodium content Caused by volume depletion e.g diabeties Replace water (IV sodium chloride and glucose)

Question 40

HYPOnatraemia

Answer 40

Symptoms; drowsiness, confusion, convulsions, N/V, cramps Drug causes thiazide/ loops, desmopressin, antidepressants Mild to moderate; treat oral NaCl, sodium bicarbonate (+ glucose if water depletion) Several IV saline slowly due to risk osmotic demylenation

Question 41

HYPERcalcaemia and HYPERcalciuria

Answer 41

Hypercalcaemia; biphosphonates or corticosteroids HYPERcalciuria; bendroflumethiazides

Question 42

HYPOcalcaemia

Answer 42

Caused by osteoporosis Mild to moderate treat with Vitamin D and calcium supplements Severe acute; slow IV calcium gluconate (too rapid = arrhythmias)

Question 43

Vitamin A

Answer 43

Retinol Associated with ocular defects (dry eyes) Teratogenic Associated with increased susceptibility to infections Rare deficiency in the UK Found in; liver, pates, fish, liver and raw eggs

Question 44

Vitamin C

Answer 44

Ascorbic acid Essential in scurvy, gingival bleeding and petechiae Helps aid iron absorption and protect cells, wound healing, collagen formation Found in oranges, peppers, tomatoes and blackcurrant

Question 45

Vitamin E

Answer 45

Tocopherol Powerful antioxidant; protects free radicals, healthy skin, eyes Little evidence for value Nuts seeds and plants

Question 46

Vitamin D

Answer 46

Colecalciferol Prevention and treatment of rickets and osteomalacia Occurs with limited exposure to sunlight or diet deficiency Alfacalcidol (active form); used in severe renal impairment patients who need vitamin D

Question 47

Vitamin B

Answer 47

B1; thiamine used wenickes encephalopathy e.g fortified cereal, whole grains B2; riboflavin; healthy skin , nerves, eyes e.g mild, egg fortified cereals, rice B3; Niacin; nicotrinamide or nicotine acid; healthy eyes and skin e.g meat, fish, egg, milk B6; pyridoxine; prevents peripheral neuropathy, helps make neurotransmitters B7; biotin; strengthen hair and nails, essential for fat metabolism B12; hydroxocbalamin / cobalamin; treats Megaloblastic anaemia, B12 deficiency; healthy nervous system, makes RBC, processed folate e.g meat, salmon fortified cereals

Question 48

Fat soluble vitamins

Answer 48

A D E K

Question 49

Diagnosing anaemia

Answer 49

Shape (sickle cell) Size (big = megabblastic or small = microlyric iron ) colour Counting (low count is haemolytic) Measure their Hb Pact cell volume

Question 50

Red flags anaemia

Answer 50

Over 60 Rectal bleeding All men and post menopausal women Treatment failure Patient unable to tolerate treatment

Question 51

Denosumab

Answer 51

Used for osteoporosis MHRA alert for hypocalcaemia

Question 52

Lansoprazole and magnesium levels

Answer 52

Causes HYPOmagnesium Common after 1 year of use Increase falls and c.diff

Question 53

Hypophosphataemia

Answer 53

Caused by decreased intestinal absorption, increased urinary excretionn re-distribution into cells Hyper is treated by sevelamar

Question 54

Bleeding or high INR > 8 warfarin

Answer 54

Give Vitamin K

Question 55

Hyperparathyroidism

Answer 55

Give vitamin D Active formal calcitol and alfacalcidol