Differential Diagnosis Of Anemia Research Articles

High Sensitivity New Parameters for the Detection of Vitamin B12 and Folate Deficiencies

The classical flow charts used widely for the diagnostic approach of anemia due to Vitamin B12 (B12) deficiency or Anemia due Folate deficiency includes the Mean cell Volume of the red blood cells (MCV) as one of the key tests for the suspicion of these diseases and the differential diagnosis of anemia. In our experience, only around half of the patients with B12 deficiency (B12) or Folate deficiency have high MCV, in many of the situations because the coexistence of other causes of anemia. The majority of the actual hematology analyzers provide information about Red cell size (MCV), Reticulocyte Volume (MRV) and Platelet Volume (MPV) Recent hematology instruments provide research data about the size of some of the White Blood Cells (WBC) as the LH700 Series from Beckman Coulter We designed a study to find which tests can help to improve the detection/flagging of these deficiencies. We collected blood samples from 58 individuals that came to the hospital and were considered as normals by the physicians. We collected 108 cases with anemia defined according the WHO anemia criteria (Hb<12 g/dL in women and Hb<13 g/dL in men.) from the hospital laboratory samples. The WHO criteria of anemia was the only condition considered. After this, samples were randomly selected from the anemic patients. We analyzed in both groups the CBC-Diff, the reticulocyte %, # and Reticulocyte related parameters, WBC Research Population Data, Serum Iron, Serum Ferritin, B12, Serum Folate, RBC Folate, Serum EPO, Transferrin, CRP, and Intrinsic Factor Antibody and checked the efficiency of the hematological parameters and research data (Mean Volume of Neutrophils and Monocytes) to detect the presence of B12 deficiency, Folate deficiency or both. We have compared B12 and Folate deficiencies with normals and also with the rest of anemias, looking for the different cut-off values in both situations. We also studied two patients with Serum B12 and Serum Folate deficiencies respectively, and followed over time the evolution of the previous tests listed above after a successful treatment.The study population included 82 males (49.4%) and 84 females (50.6%). We found that 5,2 % of the “normal” patients with normal Hemoglobin have B12 deficiency (B12 < 145 pg/mL) 5.2 % of the “normal” with normal Hemoglobin have intermediate values of B12 (B12 > 145 <180 pg/mL) and 3.45 % of the “normal” have low serum Folate. From the group of anemic patients, we found that the prevalence of B12 deficiency was 21/108= 19.4%, the prevalence of intermediate B12 was 3/108= 2.8%, the prevalence of serum folate deficiency was 10/108= 9.3%, and there were two cases with serum folate deficiency that also have respectively B12 deficiency (1/108= 0.9%) or B12 in intermediate values (1/108= 0.9%)B12 def vs NormalsMann WithneyT-TestROC AUCSensSpecifCut.offsignif.ROCMCVp=0.3156p=0.95330.577MPVp=0.00010.80279.280.6<8.3p=0.0001@NE Mean Volumep<0.00010.86283.377.8>140.3p=0.0001@MO Mean Volumep<0.00010.82962.588.9>172.3p=0.0001MRVp=0.01130.7055096.4>113.3p=0.0051Folate def vs NormalsMann WithneyT-TestROC AUCSensSpecifCut-offsignif.ROCMCVp=0.0798p=0.64610.665MPVp<0.00010.8328180.6<8.3p=0.0001@NE Mean Volumep=0.00080.8795.269.4>140.2p=0.0001@MO Mean Volumep=0.00020.80166.783.3>169.6p=0.0001MRVp=0.00540.73147.696.4>113.3p=0.0019The analytical sensitivity/sensitivity/cutoffs are specific for this study only.The @Mean Neutrophil Volume (@MNE V) and @Mean Monocyte Volume (@MMOV) may be used for the detection of megaloblastic neutrophils and monocytes. Megaloblastic Neutrophils and Megaloblastic monocytes may be seen in Megaloblastic anemias due to B12 and/or folate deficiency. MNEV and MMOV have significantly higher sensitivity than the previous information from the red cells (MCV) detecting B12 or folate deficiency because they are not affected by the presence at the same time of Iron deficiency or other reasons of anemia. @ Research use only parameters

The Possibility of Occult Lead Poisoning

To the Editor: In their review of anemia in the elderly, Steensma and Tefferi underestimate the importance of lead poisoning.1Steensma DP Tefferi A Anemia in the elderly: how should we define it, when does it matter, and what can be done?.Mayo Clin Proc. 2007; 82: 958-966Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar Lead-containing hair dyes, available over-the-counter in most drugstores, can cause anemia in the elderly due to transdermal absorption. This possible chronic toxic effect from absorption of lead is increased if the skin is irritated. The hair dye labels advise that the product should not be applied to irritated skin. However, people who use these products to appear younger by coloring gray hair probably ignore this warning, as well as warnings about frequency of use. The success of this hair-coloring product depends on repeated applications. In my experience, the topic of hair dye is often considered “off limits” or overlooked when physicians examine patients and elicit medical histories. If physicians recognize this occult possibility in their patients, perhaps lead poisoning could be eliminated from the differential diagnosis of anemia in the elderly and the resulting sequelae. The best-known and studied toxic effects of lead poisoning occur in heme synthesis. Recently the media have drawn attention to the exposure of lead in toys imported from China.2Lipton ES Barboza D As more toys are recalled, trail ends in China. New York Times.http://www.nytimes.com/2007/06/19/business/worldbusiness/19toys.htmlDate: June 19, 2007Google Scholar Lead paint in older houses in the United Sates has long been recognized as an environmental hazard. Oral ingestion of lead-based paint is serious in young children and represents most cases of lead poisoning in this age group. In adults, the presenting symptoms can be attributed to other factors, and the possibility of lead toxicity is often overlooked, especially in older men. Adult men are also at risk of lead toxicity because of occupational exposure. Most toxic effects of non-lead-containing hair dyes for women are related to accumulative abuse, with scalp scarring and damage to the hair shafts. On a recent trip to China, I found it disturbing that young and adult Chinese people in the cities were using lead-based hair dyes to make their hair darker to mimic Western fads. Media attention has encouraged some Chinese manufacturers to omit the labeling of lead content in these products. In adult patients, multisystem disease due to lead toxicity should be considered when symptoms and signs are abdominal pain, hemolytic anemia, neurologic dysfunction (mononeuropathy including headache), gout, or renal insufficiency. Questions about hair dyes need to be included in the medical history. The Possibility of Occult Lead Poisoning–ReplyMayo Clinic ProceedingsVol. 83Issue 3PreviewWe thank Dr Brown for drawing attention to an unusual cause of anemia that can affect elderly persons. Although the magnitude of risk from hair dyes is uncertain,1–3 environmental exposure to lead is common enough that lead intoxication should routinely be considered in the differential diagnosis of unexplained anemia, especially in patients from outside the United States.4 In addition to the paint and toys mentioned by Dr Brown, nonoccupational sources of lead exposure have included ceramic glazes5 (a potential danger for nursing home residents participating in ceramic arts programs6), traditional medicines,7 cosmetics (especially kohl-based eyeliner8), candy,9 metal lunchboxes,10 and several others. Full-Text PDF

Concurrent inflammatory bowel disease and myelodysplastic syndromes

Myelodysplastic syndromes (MDS) may be associated with inflammatory bowel disease (IBD). We characterized the clinical features and outcomes of patients with concurrent IBD and MDS. Using a diagnostic index, we identified all patients with both IBD and MDS at our center between 1976 and 1997. We also calculated an incidence rate of MDS in IBD using population-based data from Olmsted County, Minnesota, between 1950 and 1993. Among ˜15,000 IBD patients seen, 25 (˜0.17%) were diagnosed with MDS. Fourteen had Crohn's disease and II had ulcerative colitis. The median age at diagnosis of IBD, particularly Crohn's disease, was higher than expected. Median age at diagnosis of MDS was typical. All but one ulcerative colitis patient was diagnosed before the diagnosis of MDS, while one-half of Crohn's disease patients were diagnosed with both ailments simultaneously. Five patients who had been diagnosed with IBD first were persistently anemic for at least 1 year prior to diagnosis of MDS. Two Crohn's disease patients had received purine analogs in the past. Median follow-up after MDS diagnosis was 1 year. Seven patients died, including two who progressed to acute myeloid leukemia. The incidence rate of MDS in IBD based on Olmsted County data was 0 cases per 100,000 person-years (95% CI, 0-55.2). The seemingly high frequency of myelodysplastic syndromes in a large referral-based group of patients with IBD suggests an association; however, an increased risk of MDS was not observed in a small regional cohort of IBD patients. Patients with MDS are diagnosed with concurrent IBD at an age older than expected. Simultaneous diagnoses were made in one-half of Crohn's disease patients. MDS should be considered in the differential diagnosis of anemia in IBD patients.

Usefulness of Peripheral Blood Smears in Identifying the Causes of Anemia in Adults.

Anemia is common in hospital patients, being found in about half of the automated complete blood counts (CBCs) done on adults aged 20+ at our hospital. Often the reason for the anemia is immediately apparent (post-operative state, end stage renal disease without erythropoietin treatment), but often it is not. Many tests are available for the differential diagnosis of the causes of the anemia. Morphologic evaluation of a Wright-stained blood smear by a skilled observer is labor intensive, but sometimes useful in the differential diagnosis of anemia. When unexplained anemia is identified in a patient on the Medical Service at our teaching hospital, the ward team may also send an intern or a medical student to check out the smear. The potential diagnostic yield of any of these evaluations (the skilled observer, the intern, the student) is unknown. We did a prospective evaluation of 202 consecutive adults with initially unexplained anemia (Hb <12 in men, <11 in women). Using accepted, pre-established criteria for etiologic diagnosis of the causes of anemia, and available data (plus additional smear evaluations by ourselves, ferritins, free erythrocyte protoporphryns, and a few other tests) we felt we were able to establish the causes of anemia in 86% of the patients. We also referred to standard morphologic criteria for diagnosing specific blood disorders in order to see how much could be learned from the blood smears of these patients, alone. Of 147 patients whose blood smears were of acceptable quality, 30 (21%) of the blood smears were diagnostic (or close to diagnostic), and an additional 46% were supportive of the correct diagnosis. For example, iron deficiency anemia was considered the morphologic diagnosis if the blood smear showed severe hypochromia, “pencil-form” elliptocytes, and thrombocytosis. Hypochromia alone would be considered supportive of the diagnosis of iron deficiency, but require more consideration of alternatives (thalassemia trait, chronic disease, etc). Thus, in evaluating anemia in adults, a good peripheral blood smear, carefully evaluated by a trained observer, is likely to be diagnostic, or very helpful, in 20% or more of the patients.

2004 Japanese Society for Dialysis Therapy Guidelines for Renal Anemia in Chronic Hemodialysis Patients*

The guideline committee of Japanese Society for Dialysis Therapy (JSDT), chaired by Professor F. Gejyo of Niigata University, now publishes an original Japanese guideline entitled 'Guidelines for Renal Anemia in Chronic Hemodialysis Patients'. It includes the re-evaluation of the usage of recombinant human erythropoietin (rHuEPO) with the medical and economical arguments regarding the prognosis and the quality of life of Japanese hemodialysis patients. This guideline consists of 7 sections. The first section comprises the general definition and the differential diagnosis of anemia. The hemoglobin (Hb) level of the Japanese population seemed to be low when compared with that of the European and American populations. The second section describes the target Hb level in hemodialysis patients. Multivariate analysis of the data that were collected from dialysis institutions throughout the country showed that an Hb level of 10-11 g/dL (Ht level 30-33%) at the first dialysis session in a week is the ideal range for chronic hemodialysis patients in terms of the 3-5 year survival rate. The supine position at blood sampling and the sampling timing at the first dialysis session in a week might affect the lower setting of target Hb hematocrit (Ht), compared to that of European and American guidelines. However, we particularly recommended that an Hb level of 11-12 g/dL (Ht level from 33 to 36%) at the first dialysis session in a week is desirable in relatively young patients. In the third section, the markers of iron deficiency are discussed. The Transferin saturation test (TSAT) and serum ferritin were emphasized as the standard markers. The routes of administration of rHuEPO and its dosages are written in the fourth section. The subcutaneous route was associated with the occurrence of secondary red cell aplasia due to anti-rHuEPO antibodies; however, secondary red cell aplasia was seldom observed in the venous injection. From this fact we recommend venous injection for chronic hemodialysis patients. We advocate an initial dosage of 1500 U three times per week. The fifth section deals with the factors refractory to treatment with rHuEPO. If the patient shows an inadequate response to the usage of 9000 U per week, this condition defines the inadequate response to rHuEPO in Japan. Blood transfusion must be avoided where possible. The reasons for this and the adverse effects are interpreted in section six. In the final section, the adverse effects of rHuEPO are listed. Among them, hypertension, thrombotic events and secondary red cell aplasia were emphasized as the major complications.

Conventional and new laboratory parameters in the evaluation of hematologic disease

Laboratory investigation plays a crucial role in the workup of hematological disease. The well established method of morphological analysis of blood components has been continuously complemented by other methods. On one hand, these consist of considerable improvements of methods employed for automated cell enumeration allowing for early and accurate detection of cell subpopulations, and quantification of valuable red cell parameters, which are of use in the differential diagnosis of anemia. On the other hand, several parameters for the differentiation of microcytic anemia have become available often allowing for the sometimes difficult diagnosis of anemia of chronic disease, iron deficiency anemia, or thalassemia (ferritin, soluble transferrin receptor, transferrin saturation, RDW, zinc protoporphyrin, as well as reticulocyte indices CHr, Ret-Y Hypo%). In macrocytic anemia, introduction of methods to measure methylmalonic acid (MMA), homocystein, holotranscobalamin (holo-TC), complement the determinations of vitamin concentrations (vitamin B12, folic acid in serum and erythrocytes). Employing these newer parameters in addition to the well established ones allows for detection of early or combined disease. The clinician has to know the diagnostic characteristics not only of the old but also of the newer parameters.

Immune hemolysis-serological and clinical aspects.

The differential diagnosis of anemia must consider immune hemolytic anemias as a frequent cause. Whereas detection of anti-red blood cell (RBC) alloantibodies frequently induced by immunogenic stimuli (transfusion, pregnancy) is performed by routine serology, diagnosing autoimmune hemolytic anemias or drug-induced hemolytic anemias remains a challenge, usually requiring close collaboration of a number of disciplines. Positive direct antiglobulin test (Coombs' test) represents a central criterion in diagnosing immune hemolytic anemias, leading to further detailed analyses. The most-severe type of immune-mediated hemolysis is acute intravascular hemolysis after ABO incompatible RBC transfusion. This review highlights underlying biochemical aspects, immunohematological diagnostics, and the clinical relevance of RBC allo- and autoantibodies, including paroxysmal nocturnal hemoglobinemia and drug-induced hemolysis. Finally, current and partly experimental therapeutic strategies of immune hemolytic anemias are summarized.

Concurrent inflammatory bowel disease and myelodysplastic syndromes.

Myelodysplastic syndromes (MDS) may be associated with inflammatory bowel disease (IBD). We characterized the clinical features and outcomes of patients with concurrent IBD and MDS. Using a diagnostic index, we identified all patients with both IBD and MDS at our center between 1976 and 1997. We also calculated an incidence rate of MDS in IBD using population-based data from Olmsted County, Minnesota, between 1950 and 1993. Among approximately 15,000 IBD patients seen, 25 (approximately 0.17%) were diagnosed with MDS. Fourteen had Crohn's disease and 11 had ulcerative colitis. The median age at diagnosis of IBD, particularly Crohn's disease, was higher than expected. Median age at diagnosis of MDS was typical. All but one ulcerative colitis patient was diagnosed before the diagnosis of MDS, while one-half of Crohn's disease patients were diagnosed with both ailments simultaneously. Five patients who had been diagnosed with IBD first were persistently anemic for at least 1 year prior to diagnosis of MDS. Two Crohn's disease patients had received purine analogs in the past. Median follow-up after MDS diagnosis was 1 year. Seven patients died, including two who progressed to acute myeloid leukemia. The incidence rate of MDS in IBD based on Olmsted County data was 0 cases per 100,000 person-years (95% CI, 0-55.2). The seemingly high frequency of myelodysplastic syndromes in a large referral-based group of patients with IBD suggests an association; however, an increased risk of MDS was not observed in a small regional cohort of IBD patients. Patients with MDS are diagnosed with concurrent IBD at an age older than expected. Simultaneous diagnoses were made in one-half of Crohn's disease patients. MDS should be considered in the differential diagnosis of anemia in IBD patients.

The Differential Diagnosis of Anemia, Thrombocytopenia and Bone Dysplasia

The Differential Diagnosis of Anemia, Thrombocytopenia and Bone Dysplasia

The anaemic child

Except in babies, who may become tachypnoeic during feeding, anaemia in children usually presents with pallor and tiredness, rather than breathlessness. The degree of anaemia, therefore, may be much more marked than in adults and it is not uncommon for the haemoglobin concentration (Hb) to fall as low as 4 g/dl before the family becomes aware of any problem. Clinical recognition of pallor due to mild to moderate anaemia is difficult, and in the context of an unwell or lethargic child, should lead to a relatively low threshold for performing a full blood count (FBC) and film. A perfectly adequate specimen can be obtained from an ear or finger prick, which should ideally be performed by experienced personnel. The mean corpuscular volume (MCV), red blood cell count (RBC) and the red cell morphology on the blood film, interpreted against ethnically appropriate norms, provide the critical information the clinician requires to formulate a differential diagnosis of anaemia in the majority of children. Although pregnancy in schoolgirls is distressingly common, the changes in Hb and MCV during pregnancy will not be covered in this article.

Flow cytometric reticulocyte analysis and the reticulocyte maturity index.

Reticulocyte analysis has evolved to one of the accepted and routinely practiced clinical applications of flow cytometry technology. Similar to CD4 measurements, FCM technology has contributed to documented improvements in reticulocyte counting precision over previous microscope-based techniques. The ability to FCM instruments to quantitate fluorescence intensity has been utilized to derive a parameter of reticulocyte maturity, which we have termed the reticulocyte maturity index. The FCM-derived RMI parameter offers an additional perspective to assess the erythropoietic response in anemic patients over reticulocyte counting alone and provides further insight into the differential diagnosis of anemia. Clinical utility of the RMI has been reported in monitoring expensive, new-technology therapies, such as bone marrow transplantation and erythropoietin therapy. FCM reticulocyte analysis is still not fully mature, but is in a state of continued evolution. Needs exist for (i) improved software for data analysis, (ii) newer automation techniques to improve interlaboratory correlations, and (iii) further validation and refinement of the reticulocyte maturity index parameter.

Differential diagnosis of anaemia in dogs

Differential diagnosis of anaemia in dogs

Anemia in the newborn: a diagnostic approach and challenge.

T he normal mean hemoglobin at birth is 16.5 g/dL with a range of 13 to 21 g/dL. Intrauterine growth retardation, maternal diabetes, post maturity and maternal cigarette smoking, are all associated with higher levels of hemoglobin, probably as a consequence of hypoxia or stress. Because of significant capillary hemoconcentration in the first few days of life, a venous specimen is essential for accuracy. Although a hemoglobin level of less than 13 g/dL is, by itself, indicative of significant anemia, values at the lower end of the range may be seen with a variety of pathological states and must be evaluated in concert with physical signs, reticulocyte count, and bilirubin levels. The differential diagnosis of anemia in the newborn infant is more extensive than in later life because there may be both maternal as well as infant causes. However, the approach to the anemic neonate does not differ substantially from the diagnostic approach that is used in later life. Essential information in evaluation of the anemic neonate includes a family history and a description of the pregnancy, including the mother’s health and medications, and the circumstances of the birth. Basic initial laboratory studies include a complete blood count (including RBC) red cell indices, reticulocyte count, an evaluation of red cell morphology, a direct Coombs’ test, and serum bilirubin. Table 1 lists hematologic values for normal term and premature (32 week) infants. After it is ascertained that the newborn is anemic, a stepwise approach to diagnosis is outlined on Fig 1. As in the older patient, there are only two fundamental mechanisms for anemia in the

Enalapril-Associated Anemia in Renal Transplant Recipients Treated for Hypertension

We encountered a renal transplant recipient who developed an unexplained 0.09 decrease in hematocrit value while taking enalapril for hypertension, which reversed when the drug was stopped. This experience, and a previous similar case report, prompted a review of all our 27 transplant patients treated with enalapril. Of these, 10 patients (37%) had developed an otherwise unaccounted for anemia: the pre-enalapril hematocrit value was 0.42 +/- 0.01 and it decreased to the nadir value of 0.33 +/- 0.01 (P less than 0.001) within 12.3 +/- 0.9 weeks after initiation of 9 +/- 2.4 mg of enalapril daily; enalapril was stopped in seven patients and their anemia resolved within 9.1 +/- 0.7 weeks to a final hematocrit value of 0.40 +/- 0.01. The remaining three patients were maintained on enalapril at their physicians' discretion, without further decrease in hematocrit values. No appreciable changes in drug regimens, clinical course, or other laboratory parameters were noted during this period. A causal relationship between enalapril and anemia was suggested by the effect of drug withdrawal and rechallenge on hematocrit in one of the patients. There were no statistically significant differences in baseline clinical and laboratory characteristics between those patients who did (group I) and those who did not (group II) develop enalapril-associated anemia, with the exception of a normal hematocrit value of 0.42 +/- 0.01 in group I versus a lower hematocrit value of 0.36 +/- 0.02 in group II (P less than 0.05). We conclude that enalapril should be considered in the differential diagnosis of anemia following renal transplantation. Susceptibility to this effect might emanate from the immunosuppressed state.

The aetiology of severe anaemia in pregnancy in Ndola, Zambia.

The aetiology of severe anaemia (haemoglobin less than 7.0 g dl-1) has been studied in 37 pregnant Zambians. Aetiology was usually multiple; 31 (84%) had Plasmodium falciparum malaria, 23 (62%) were folate deficient, 13 (35%) were iron deficient, one had sickle-cell anaemia and one had the acquired immunodeficiency syndrome (AIDS). Folate deficiency was most often secondary to malarial haemolysis: iron deficiency was nutritional, but hookworm was contributory in about one-third of patients. The anaemia of malaria and folate deficiency was both more common and more severe than anaemia due to iron deficiency; it was seen in younger women although primigravidae were not over-represented, it occurred earlier in pregnancy, and was associated with low birthweight. AIDS must now be included in the differential diagnosis of anaemia in pregnancy. Vigorous antimalarial treatment and prophylaxis are essential in the management and prevention of anaemia in pregnancy. Total dose iron infusion is indicated only when severe iron deficiency anaemia has been proven, and must be accompanied by antimalarial therapy and folic acid supplements. Because of the risk of transmission of human immunodeficiency virus, it is more important than ever to prevent anaemia and malaria in pregnancy, and to give blood transfusion only as a life-saving treatment.

Anemia

The differential diagnosis of anemia is made easier by classifying RBC morphology as (1) hypochromic and microcytic, (2) normochromic and normocytic, and (3) macrocytic. This limits the number of diagnostic considerations and, hence, limits the laboratory evaluation. There are relatively few considerations if the RBCs are hypochromic and microcytic, including iron deficiency and the thalassemia syndromes. If the RBCs are normochromic, the reticulocyte percentage indicates whether the bone marrow is providing an appropriate response for the degree of anemia. There also are few possibilities if the reticulocyte percentage is low, ie, Diamond-Blackfan syndrome and transient erythroblastopenia of childhood. In the absence of bleeding, a brisk reticulocyte response indicates hemolysis due either to an intrinsic (congenital) or to extrinsic (acquired) RBC defect. The patient's history and physical examination findings may provide additional clues, and RBC features such as irreversibly sickled cells or spherocytes may indicate a specific diagnosis. Finally, the macrocytic anemias are suggested when the MCV exceeds 100 fL per cell and there are macroovalocytes on the blood smear. Such findings warrant further exploration of vitamin B12 and folic acid deficiency syndromes.

Evaluation of Erythrocyte Disorders With Mean Corpuscular Volume (MCV) and Red Cell Distribution Width (RDW)

The red cell distribution width (RDW), which provides a quantitative measure of heterogeneity of red cells in the peripheral blood, and the mean corpuscular volume (MCV) are part of the routine red cell indices reported by automated blood analyses. This study evaluated 193 pediatric patients with a wide range of erythrocyte disorders and determined the diagnostic utility of the RDW in relation to the MCV. Six different groups of erythrocyte disorders by MCV and RDW values are described: low MCV/normal RDW, low MCV/high RDW, normal MCV/normal RDW, normal MCV/high RDW, high MCV/normal RDW, high MCV/high RDW. This combination established a useful differential diagnosis of erythrocyte disorders. The data provided a baseline against which future studies of infants and children can be compared, though each laboratory has to verify its own normals. It should be cautioned that different electronic counters yield different RDW values, so there have to be qualifications when reporting reference values. The RDW may find its best use as a guide in the differential diagnosis of anemia, rather than as a definitive test per se.

A computer system applying the face method to represent multiphasic tests.

The results of medical examinations have recently become multiphasic with few exceptions, and various graphical methods exist to represent the results concisely. One of these graphical methods is reported here, utilizing a computer system for applying the so-called 'face method'. This displays the condition of an individual's health by erythrocyte count, leucocyte count, haemoglobin, erythrocyte sedimentation rate, systolic blood pressure and diastolic blood pressure, all the information being accessible via a database system. Only keywords are necessary to display faces representing the health condition. Graphical methods are useful for providing data features because they appeal to the eye. The face method is more practical than other graphical methods in that its features give easily recognizable indications. The face method can be utilized in various ways, for example in differential diagnosis of anaemia, and to comprehend time-based changes in an individual's health condition based on multiphasic tests.

Essential thrombocythaemia in the dog and cat: a report of four cases

ABSTRACTThe occurrence of essential thrombocythaemia in the dog and cat is recorded. In four cases of anaemia profound elevation of platelet numbers was noted. Bone marrow biopsy revealed megakaryocyte proliferation, with excessive platelet production and abnormal megakaryocyte morphology. This condition should be considered in the differential diagnosis of anaemia.

HbE-β-Thalassemia Associated With G6PD Deficiency

HbE, beta thalassemia, and G6PD deficiency were demonstrated in a 6-year-old Mexican-American child with anemia, jaundice, and delayed growth. The father was heterozygous for HbE, and the mother for beta-thalassemia and G6PD deficiency. The association of these three diseases should be included in the differential diagnosis of anemia in childhood, particularly after the recent influx of people form Southeast Asia into the United States.