Iron Balance and Deficiency

Iron is an essential part of hemoglobin (heme portion), myoglobin in muscles, certain enzymes in mitochondria etc. It is stored in the form of ferritin in the body and transported in the blood as transferrin.

The average body of adult humans has 3 to 4 gms of iron, women have about ½ gm less than their male counterparts. About 2.5 gms of iron is in the redblood cells (formed or forming) and ½ to 1 gm is in the storage form. Circulating iron in plasma is 5 to 7 mg and about ½ gm is in myoglobin and various enzymes.

Diet in western countries contains about 10-15 mg of iron daily. In the Asian countries quantity of iron is about ½ to 2/3 of the western diet. Non-vegetarian food iron is absorbed to the extent of 30 % while in vegetarian food only about 10 % of iron is absorbed. Phytates, tannates, phosphates reduce iron absorption while vitamin C enhances it. Iron in vegetarian food is in ferric form and absorption is mainly in ferrous form.

25 to 30 mg of iron may be released from dying RBCs and most of this is very efficiently reused by the body. Iron is lost from the body in sweat, skin and gastrointestinal cells which are shed continuously from the lining of skin and GIT.

Iron is absorbed mainly from duodenum and absorption increases in iron deficiency states. It is decreased in iron surplus states.

Iron deficiency results in anemia with small RBCs which have  reduced hemoglobin. The deficiency states are diagnosed by S Iron , S ferritin, S transferrin level and RBC indices.

Common causes of Iron Deficiency are

Reduced dietary intake

Increased losses in the body from bleeding (menstruation, worms, GI bleeds, nose bleeds , injuries )

Reduced absorption (antacids, GI diseases)

Most woman are chronically deficient in Iron due to menstrual losses and their Hemoglobin is closer to 13 compared to 15 in men. Iron deficiency anemia is a common cause of poor health , fatigue, pregnancy complications etc.

Treatment of Iron deficiency

By increasing dietary Iron (fortified wheat flour) etc and iron supplements in the form of oral and injectable iron preparations. Oral drugs are safer but may cause GI Side-effects. Most Injectable preparations available nowadays have few serious reactions but these have to be administered under supervision.

Chest Pain

Chest Pain is a common yet difficult condition to diagnose. Most chest pains or discomforts are benign, however, some may be a harbinger of serious cardiac emergencies. It is often alarming as the 1st episode may result in instantaneous collapse and sudden death.

About 2/3rds of chest pain are non-organic. Non-organic means not due to heart, lungs, esophagus diseases. About 30 % are due to muscular or rib conditions and about 10% are due to esophagus related disorders. Serious chest pains only form about 10% of the patients attending a doctor. However as the 1st episode itself may be due to a “heart attack” or Acute Myocardial Infarction, all chest pain cases need to be dealt with in detail. The episodes which also include heart attacks, unstable anginas or similar pains due to suspected heart ischemia are clubbed together as Acute Coronary Syndrome or ACS. This helps in deciding which patients need to be admitted or observed.

Ischemic chest pains may be recurrent, appear after a certain quantity of physical exercise, get relieved by rest or nitrate tablets under the tongue are called angina or stable angina.

The ones due to Myocardial Infarctions may be difficult to describe, occur only once or a few times in the life of an individual. These may spread to one or both arms, shoulder/shoulders or jaws. This can be accompanied by nausea, vomiting, collapse, profuse sweating or fatigue. These increase over minutes to hours. In case a myocardial infarction is suspected, aspirin in a dose of about 300 mg is given to the patient to be chewed. In case blood pressure is stable, he or she is given a sublingual nitrate and oxygen is administered if blood levels are low or not available.

Chest pains which have increased in frequency, occur at night, have become more severe or longer lasting, occur at night may suggest Unstable Angina.

Women may describe the pain as more severe and sharp compared to men.

The diagnosis of most of these cases is based on meticulous history, ECGs, Cardiac enzymes and serial observations of these. Based only on clinical evidence the diagnosis may often be wrong.

In cases of chronic stable angina, stress testing, isotope scan (Stress Thallium), provocation tests or angiography may be required.

It is important to know the risk factors for the likelihood of ischemic disease. These are age, male sex, smoking, high blood pressure, diabetes, high levels of lipids in the blood, sedentary lifestyle etc. The more the risk factors, the more likely is the occurrence of ischemic heart disease.

Non-organic cases may be due to anxiety, panic disorders etc. Musculo-skeletal causes include costochondritis (inflammation of rib cartilages). Acid peptic disease, diseases of lungs are also common but relatively simpler to diagnose. Very severe tearing pain may rarely be due to a tear in the aorta (called aortic dissection) and in hospitalized patients, Pulmonary Thromboembolism may be the underlying cause. These are rare but result in fatalities if remain undiagnosed.

Headache

Headache is one of the commonest symptoms causing significant distress to patients. Chronic headaches may recur for years and cause economic, social, psychological and physical issues. 90% of the headaches are benign.

Headache includes pain in the area above the neck including the face. Chronic headaches are common and affect about 40 to 45 % of the population. Chronic headaches may be called tension headaches, migrainous or cluster headaches. The pain may be cutting, shearing, burning, dull or sharp, deep or superficial, throbbing, waxing or waning and of many other types.

Tension headaches often produce a band like sensation or tightness in the head. These are not due to tension in the muscles as is commonly believed. These are also not due to “ Tension or Stress”. The exact mechanism is not clear.

Migrainous headaches are usually throbbing, maybe in one half or both sides, usually last for a few hours to 1 or 2 days, and may be relieved by vomiting or sleep. A patient may know few hours before the onset of a headache that he or she is going to get one. These may affect up to 40 % of the population. These can be effectively prevented and decreased by medicines in most patients.

Cluster headaches are rare (about 1% of all headaches), occur in groups occurring daily for a few weeks to months, last for lesser duration (few minutes to 2-3 hours) and are throbbing. These are severely disabling in nature.

Sinus headaches are usually localized to the area around sinuses. These may be aggravated by sniffing or deep breathing.

Headaches due to meningeal irritation or infection are rare but serious and if not treated rapidly may be fatal. These are usually localized to the back of the head and upper part of the neck up to the shoulders. These may be aggravated by bending the neck forwards. These are often severe, occur with fever or in epidemics, have associated vomiting and cause prostration very early.

Headaches due to brain tumours are often deep-seated, worse at night and worsen with time over days, weeks and months. Associated vomiting (forceful and often sudden) are common.

Most fevers can have headaches associated with them. The headache may increase and or decrease with temperature.

Dangerous Signs of Headaches :

Severe headache coming on suddenly and worsening over seconds to minutes and occurring for the 1st time in life may suggest a bleeding in the brain. Headaches progressively worsening may be due to tumours. Headaches with neurological signs i.e paralysis, double vision, loss of vision or hearing on one side, fits or changes in the level of consciousness, change in voice, inability to speak or comprehend etc usually mean organic (affecting structures of the brain) headaches.

Psychiatric conditions like depression may cause headaches or headaches may cause depression. Headaches may be a side effect of various drugs.

The diagnosis of headaches is usually by a detailed history and relevant clinical examination. X-Ray Skull, CT Scan of the brain and neck spine or MRI may be required for the diagnosis of brain tumours or bleeding.

Chronic headaches are difficult to treat and test the patience of the doctors and the patients both.

Human Organ Transplant Act

Indian parliament in July 1994 formulated HOTA to regulate transplant activities in India. This was necessitated by acts of selling and buying organs prevalent at the time and which had brought Indian medical system into disrepute all over the world.

This act immediately came into force in Goa, Himachal Pradesh, Maharashtra and Union Territories. This had to be ratified by various states before it could be applied to the rest of the country. Some of these states took a very long time before the act was applied.

In 2014, the act has been almost totally revised. The main aim of the act is to regulate all transplant activities, provide stringent punishment to offenders indulging in organ sales and traffic, clarify the confusing points in previous act and add grandparents to the list of near relatives. It also enhanced punishment to the offenders. This act also sought to encourage cadaver donation by various means.

This law further clarified the duties of Incharge in ICUs and made it mandatory for them to apply provisions of brain death and ask relatives if they are willing for cadaver donation in case a person had not prior to his death pledged to donate his organs.

This act also included nonmedical people (from police, judiciary, teaching professions etc) to become members of the authorizing committees. These committees decide whether a willing donor in case of living donor can donate his organs. These committees are also tasked with ascertaining financial position of the donors, motivation for donating an organ and seeing that organs are not sold or bought for transplant purposes. The committees also satisfy themselves in case of spouses that the donation is voluntary and without pressure.

The act provides for periodic review of the hospitals allowed to carry out transplant activity and publish their results of transplants undertaken by these. Various states have started their websites to regulate organ allocation and maintain a list of patients awaiting organ transplant.

The success of the act will depend on how meticulously and honestly the spirit of the act influences the transplant activity in the country.

Brain Death

More than half of organ transplants in the world are carried out on organs obtained from deceased donors. In 1959 the term brain death came into vogue to describe patients who have a permanent cessation of brainstem or brain functions which are required to integrate functioning of the organism as a whole. Some tissues may still be “live” and can continue to grow in laboratories for indefinite periods. However, the organism as a whole does not live once brain death has occurred.

Conventionally brain death had been ascertained once the heart has stopped beating. However, a few heartbeats may occur for some time after the cessation of cardiac function and a few gasps may be seen. This criterion of clinical death has been replaced in most countries of the world by the concept of brain death.

In modern ICUs once brain death has occurred, spontaneous breathing does not occur. Hence patients are on ventilators and most require support to maintain blood pressure ( vasopressors).

What is brain death?

Brain death is the cessation of brain function and almost always accompanied by the stoppage of blood flow to the brain. This is in most cases due to injury as in road traffic accidents, falls or elsewhere. It is also a common result of subarachnoid bleed (bleeding inside the covering of brain in the cranial cavity).

How is brain death diagnosed?

Diagnosis of brain death requires expertise and experience.

Prerequisites for diagnosing brain death are

  • Cause of injury to the brain should be known and compatible with brain death.
  • Poisoning and drug intoxication should be excluded
  • The body temp should be above 36 C.
  • There should be no severe electrolyte or metabolic state (sugar, sodium, CO2 and O2 level)
  • Blood pressure should be >100 mm systolic

Clinical Examination :

Neurological examination reveals coma,

The absence of all reflexes originating from the brain stem.

The absence of motor activity originating from the brain (spinal cord reflexes and some involuntary movements may be seen)

Apnea test may be carried out by stopping mechanical ventilation, waiting for CO2 levels to rise and observing for spontaneous breathing. Oxygen is usually given at a high pressure before carrying out this test.

Laboratory Investigations:

These include

Tests to see absent blood flow. The methods employed may be MR Angiography, CT angiography, Nuclear scans, Trans Cranial Doppler etc

EEG and brain stem evoked potentials to ascertain activity.

These tests are usually carried out by more than one clinician. Neurologists, neurosurgeons, physicians, intensive care doctors, anesthesiologists are usually experienced in these tests. These tests are repeated after a time interval to ensure that the changes are indeed reproducible and permanent.

Most countries have their own definitions, examination patterns and requirements before brain death is declared including the qualifications of doctors declaring the same. It is equated with clinical death in most countries. However, the lack of clarity is apparent as yet there are no universally applicable guidelines.

Organs for various transplantation purposes can be obtained once brain death is declared and other laws and relatives permitting the same. The organs thus retrieved are in a reasonably healthy state as organ perfusion has continued till the retrieval and ischemia time is least.