The intuitive expectation that the underlying cause will be

By August 12, 2012Uncategorized

Much has been written about the current wave of Chinese overseas direct investment, most of which has focused on commodity resources, particularly in Africa and Latin America. And Europe for technology, however, is no less significant. Tired of paying licensing fees and royalties, Chinese firms have increasingly sought to buy breakthrough innovation capabilities through acquisitions of both technology and talent.

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pandora rings In the latter context, the coexistence of thrombocytosis and impairment of haemoglobinisation of red blood cells is attributable to the role of cytokines in thrombopoiesis, and in mobilisation of iron from reticuloendothelial macrophages.20Underlying causes of iron deficiencyThe under investigation of iron deficiency anaemia is exemplified by a study showing that, in one health district, gastrointestinal investigations for the underlying cause of this haematinic deficiency were performed in only 63% of 109 iron deficient patients aged >50,21 notwithstanding the age related prevalence of gastrointestinal causes of this disorder. The intuitive expectation that the underlying cause will be disclosed by systematic analysis of symptoms and signs17 has to be tempered with the recognition that, even in the absence of symptoms, as many as 44% of adults with iron deficient anaemia will harbour gastrointestinal lesions capable of causing chronic blood loss.22 When symptoms are present, the positive predictive value for upper gastrointestinal tract lesions (range 18% 86%, median 60%), can be almost twice as high as it is for lower gastrointestinal tract pathology (range 28% 52%, median 35%).23 28 This might be a reflection of the fact that an analysis of 1207 patients compiled from 10 studies, each enrolling >70 patients for the purpose of identifying underlying causes of iron deficiency anaemia and/or occult gastrointestinal bleeding, yielded a ratio of 491v 283 for patients with upperv lower gastrointestinal tract lesions, both sites being simultaneously involved in approximately 104 instances.23 32 In another analysis, comprising 721 iron deficient subjects aged >50, compiled from seven studies, upper gastrointestinal lesions were documented twice as frequently as those from the lower gastrointestinal tract.33 However, in view of higher prevalence of malignancy in lower as opposed to upper gastrointestinal tract lesions, iron deficient patients aged >50, including those with benign upper gastrointestinal lesions, should almost always be offered colonoscopy because it is in this age group that malignant colorectal pathology may coexist with benign lesions of the upper gastrointestinal tract.33 When this strategy was put to the test in a prospective study of 89 patients of mean age 65, 26 patients were found to have lesions in both the upper and lower gastrointestinal tract. So thorough were the investigators that as many as 14 of their subjects were subjected to small bowel barium enema studies as well.31 The principle that identification of small bowel pathology should be part of the overall strategy for investigation of iron deficiency anaemia is one which is being increasingly acknowledged, enteroscopy,34 small bowel enema (enteroclysis),35 and computer tomographic enteroclysis36 being just three of the expanding list of modalities aiming to ensure that the mistake of overlooking the existence of tumours of the small bowel (fig 1) should occur with diminishing frequency.One of the most important developments of recent times is the recognition of the extent of the aetiopathogenetic role of coeliac disease in iron deficiency anaemia, including documentation of the fact that, with a prevalence of 39%, this haematinic deficiency is the single most frequent extraintestinal manifestation of this disorder,37 and that patients aged >60 comprise up to 19% of the adult coeliac population.38Dietary deficiency pandora bracelets, when specifically sought, may be the sole cause of iron deficiency anaemia in as few as 5% of elderly patients subsisting on a Western diet.24 The recognition is equally important that hypochlorhydria (typically associated with autoimmune gastritis) may impair the bioavailability of dietary iron, with consequent iron deficiency anaemia, as in 22 patients reported with histamine fast achlohydria and parietal cell antibodies, coexisting vitamin B12 malabsorption being a feature in a subgroup of seven.39 It is also just as important to be aware of the fact that, when the two haematinic deficiencies coexist, the microcytic hypochromic haematological profile may totally disguise the presence of vitamin B12 deficiency,40 the only occasional clue being intercurrent thrombocytopenia pandora rings.

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