Download Free Medical Anemias In Children PowerPoint Presentation

Anemias In Children PowerPoint Presentation

DOWNLOAD MEDICAL POWERPOINT PRESENTATION

About This Presentation

Description : Check out this medical PowerPoint presentation titled "Anemias in children”.

This medical PowerPoint presentation is about anemia, a common condition in children that occurs when the body doesnt have enough red blood cells or hemoglobin to carry oxygen to the bodys tissues.

Several types of anemia that can affect children include Iron-deficiency anemia, Sickle cell anemia, Thalassemia, Aplastic anemia, and Hemolytic anemia.

Symptoms of anemia in children can include fatigue, weakness, shortness of breath, pale skin, and irritability. Treatment for anemia depends on the underlying cause and may include dietary changes, iron supplements, blood transfusions, or medication. Its important to talk to a doctor if you suspect that your child has anemia or if you have concerns about your childs health.

Tags : Anemias in children, anemia, Iron-deficiency anemia, Sickle cell anemia, Thalassemia, Aplastic anemia, Hemolytic anemia, Neonatal-Perinatal Medicine, Neonatal-Perinatal Medicine PowerPoint presentation

Published on : Jun 07, 2023 | Views : 1798 | Downloads : 1

Shareable Url :

Embed Code :

Comment

Transcript

Slide 1-

Anemias in children
Slide 2-

Anemia… … abnormal low hemoglobin, hematocrit or RBC count, lower than the age-adjusted reference range for healthy children.
Slide 3-

Etiologic classification I Impaired red cell formation A/ Deficiency Decreased dietary intake Increased demand Decreased absorption Increased loss B/ Bone marrow failure Failure of a single or all cell lines Infiltration C/Dyshematopoietic anemia II Blood loss III Hemolytic anemia Corpuscular (membrane, enzymatic or hemoglobine defects) Extracorpuscular (immune, idiopathic)
Slide 4-

Diagnosis of Anemia detailed history careful physical examination peripheral blood smear red cell morphology MCV RDW (red cell distribution width) WBC and platelet morphology Additionally: -bone marrow evaluation -additional testing
Slide 5-

History - Diet (iron , folate, vitB12 intake, onset of hemolysis after certain foods –e.g.,fava beans) - family history (transfusion requirements of relatives, splenectomy, gallblader disease) - environmental exposures (lead poissoning) - symptoms (headache, exertion dyspnea, fatigue, dizziness, weakness, mood or sleep disturbances, tinnitis) melena, hematemesis, abdominal pain- chronic blood loss
Slide 6-

Physical Examination Pallor (skin, oral mucosa, nail beds) Jaundice -hemolysis tachycardia tachypnea orthostatic hypotension venous hum systolic ejection murmur peripheral edema? Splenomegaly? Hepatomegaly? Glossitis? gingival pigmentation? Adenopathy? Facial, extremity examination
Slide 7-

Peripheral Blood Componentsimportant! Different values dependent on age! RBC Hgb HCT MCV – 80 – 100 fl/L (a calculated value) MCH RDW Reticulocyte Count
Slide 8-

MCV for Characterize Anemia Low(<70 fl) *Hypochromic/Microcytic -Iron deficiency anemia -Thalassemia -Sideroblastic anemia -Chronic infection -Lead poisoning -Inborn errors of Fe metabolism -Severe malnutrition -Copper deficiency (>85fl) *Macrocytic Normal newborn Increased erythropoesis Post splenectomy Liver disease Aplastic anemia Megaloblastic anemia Down S. Obstructive jaundice
Slide 9-

Normocytic Acute blood loss Infection Renal failure Connective tissue disorders Liver disease Disseminated malignancy Early iron deficiency Aplastic anemia Bone marrow infiltration Dyserythropoietic anemia
Slide 10-

Iron Deficiency Anemia Causes -Dietary deficiency -Increased demand (growth) -Impaired absorption -Blood loss (menstrual problems) Symptoms GI: Anorexia, poor weight gain, pica, atrophic glossitis CNS: fatigue, irritability Cardiac: increased cardiac output, cardiac hypertrophy Dry skin, thin hair, pallor, nail ridges
Slide 11-

Iron Deficiency Anemia *characteristics of peripheral blood smear microcytic hypochromic *MCV and Hgb– decreased (Hgb<12g/L) Ferritin – decreased (<13mg/dL) TIBC - high -Serum iron –decreased (N 50-150 µg/dL)
Slide 12-

Iron Deficiency Anemia Treatment oral iron supplementation: 4 - 6mg/kg/day of elemental iron goal: to replace iron stores, not just circulating Hgb! Reticulocytes- starts to rise in 3 -4 days, Hbg- after 4- 5 days After Hgb normalisation – continue Fe therapy 1-2 months to replace Fe stores *Iron- rich foods: animal protein, green vegetables, iron fortified cereales Folate, vit C
Slide 13-

parenteral therapy (IM,IV) indications poor compliance severe bowel disease intolerance of oral iron chronic hemorrhage acute diarrhea disorder
Slide 14-

Megaloblastic anemia Presence the megaloblasts in the bone marrow and macrocytes in the blood In > 95% occurs as a result of folate and vitamin B12 deficiency Deficiencies of ascorbic acid, tocopherol, thiamine may be related to megaloblastic anemia Dietary vitamin B12 (cobalamine) is required from animal sources (meat and milk)
Slide 15-

Causes of vitamin B12 deficiency I Inadequate dietary intake (<2mg/day) –malnutrition, veganism, maternal deficiency II Defective vitamin B12 absorption Failure to secrete intrinsic factor Failure to absorption in small intestine III Defective vitamin B12 transport IV Disorders of vitamin B12 metabolism (congenital, acquired)
Slide 16-

Folic acid deficiency One of the most common micronutrient deficiences in the word (next to iron deficiency) Component of malnutrition and starvation Women are more frequently affected than men Folate sufficiency prevents neural tube defects Low mean daily folate intake is associated with twofold increased risk for preterm delivery and low infant birth weight
Slide 17-

Causes of folic acid deficiency Inadequate intake (method of cooking, special diet, goat’ milk) Defective absorption (congenital or acquired) Increased requirements (rapid growth, chronic hemolytic anemia, dyserythropoietic anemias, malignant disease, hypermetabolic state, cirrosis, post –BMT) Disorders in folic acid metabolism (congenital, acquired) Increased excretion
Slide 18-

Clinical features of cobalamine and folate deficiency Insidious onset: pallor, lethargy, fatigability, anorexia, sore red tongue and glossitis, diarrhea History: similarly affected sibling, maternal vitamin B12 deficiency or poor maternal diet Vitamin B12 deficiency: signs of neurodevelopmental delay, apathy, weakness, irrability, athetoid movements, hypotonia, peripheral neuropathy, spastic paresis
Slide 19-

Diagnosis Red cell changes: Hgb usually reduced, MCV increased to levels 110 – 140fl., MCHC normal, in blood smear many macrocytes and macro-ovalocytes, anisocytosis, poikilocytosis, presence of Cabot rings, Howell-Jolly bodies, punctate basophilia White blood cell count reduced to 1500 – 4000/mm3, neutrophils show hypersegmentation (>5 lobes) Platelets count moderately reduced (50,000 – 180,000/mm3) Bone marrow: megaloblastic appearance Serum vitamin B12 values lowered (normal 200 – 800 pg/ml) Serum and red cell folate levels – wide variation in normal range; less than 3 ng/ml -very low, 3-5 ng/ml –low, >5-6 ng/ml normal, in red cell:74-640 ng/ml Schilling urinary excretion test – measurement of intrinsic factor availability and absorption of vitamin B12
Slide 20-

Treatment Vitamin B12 deficiency Prevention in cases of risk of vitamin B12 deficiency Treatment 25 – 100µg vitamin B12 Folic acid deficiency Correction of the foliate deficiency (100-200µg/day) Treatment of the underlying causative disorder Improvement of the diet to increase folate intake
Slide 21-

Bone marrow failure
Slide 22-

Isolated quantitative failure of one cell line, a single cytopenia , e.g. erythroid, myeloid, megakaryocytic A failure of all three cell lines (pancytopenia with hypoplastic or aplastic bone marrow) A quantitative failure of the bone marrow, e.g. congenital dyserythropoietic anemia The invasion of the bone marrow by non-neoplastic or neoplastic condition
Slide 23-

Diamond-Blackfan anemiacongenital pure red cell aplasia The erythroid progenitor cell is intrinsically abnormal in the following aspects: Decreased sensitivity to erythropoietin (EPO) Decreased sensitivity to EPO not corrected by IL-3 and GM-CSF caused by: Functional abnormalities in the erythropoietin receptors Erythroid progenitors are abnormally sensitive to a deprivation of erythropoietin, resulting in an accelerated rate of apoptosis
Slide 24-

Clinical features Anemia and pallor in first 3 months, 35 % is anemic at birth, 65% -identified by 6 months of age and 90% - by 1 year Platelets and white cell count – normal 25% have prenatal or postnatal growth failure and associated congenital defects, including short stature, abnormalities of thumbs, skeletal anormalities, congenital heart defects, webbed neck, urinary tract abnormalities and craniofacial dysmorphism Chromosomal studies generally normal No hepatosplenomegaly Malignant potential (increased incidence of ALL, AML, hepatocellular carcinoma)
Slide 25-

Diagnosis Anemia and reticulocytopenia Bone marrow with virtual absence of normoblasts Differential diagnosis Transient erythroblastopenia of childhood (TEC) Congenital hypoplastic anemia
Slide 26-

Treatment Prednisone 2 mg/kg/day, when the hemoglobin level reaches 10.0g/dl → dose reduction to minimum necessary Packed red cell transfusion, leukocyte –depleted Bone marrow transplantation in steroid –resistant, transfusion-dependent patients
Slide 27-

Fanconi anemiacongenital aplastic anemia Rare inherited disorder, autosomal-recessive trait Pancytopenia: develops between 4 and 12 years of age It may present with isolated anemia or leukopenia or anemia + thrombocytopenia Macrocytosis (high MCV), high HbF, high erythropoetin, presence of i antigen – characteristic of stress erythropoiesis Diepoxybutane (DEB)-induced chromosomal breakages Hypocellularity and fatty replacement in bone marrow congenital anomalies: patchy brown pigmentation of the skin, short stature, skeletal anomalies, hyperreflexia, hypogenitalism, microcephaly, microphthalmia, strabismus, ptosis, nystagmus, abnormalities of the ears, deafness, mental retardation, renal and cardiac anomalies Chromosomal breakages and structural abnormalities, chromatoid exchange High incidence of AML, carcinoma
Slide 28-

Treatment: Supportive: Packed red blood cells and platelets (irradiated, leukocyte reduced) Chelation treatment in iron overload Androgen therapy Active: Allogenic bone marrow transplantation
Slide 29-

Acquired aplastic anemiapathophysiology Immunologically mediated, tissue-specific, organ-destructive mechanism Exposition to an antigen → cells and cytokines of the immune system destroy stem cells in the marrow → pancytopenia Gamma –interferon plays a central role in the pathophysiology of AA T cells from AA patients secrete gamma-IFN and TNF – potent inhibitors of both early and late hematopoietic progenitor cells Cytotoxic T cells secrete also IL-2, which causes polyclonal expansion of the T cells
Slide 30-

Causes of acquired AA Idiopathic (70%) Secondary: Drugs: cytostatics, antibiotics (sulfonamides, chloramphenicol), anticonvulsants (hydantoin), antirheumatics, antidiabetics, antimalarian Chemicals: insecticides Toxins: benzene, carbon tetrachloride, glue, toluene Irradiation Infections: viral (hepatitis A, B, C, HIV, EBV, CMV, parvovirus) Immunologic disorders: GvHD Preleukemia, MDS, thymoma Malnutrition Paroxysmal nocturnal hemoglobinuria
Slide 31-

Severity Severe AA: bone marrow cellularity <25% Granulocyte count <500/mm3 platelet count <20,000/mm3 reticulocyte count <40,000/mm3 Very severe AA: granulocyte count <200/mm3
Slide 32-

Clinical findings: Anemia (pallor, easy fatigability, loss of appetite) Thrombocytopenia ( petechiae, easy bruising, severe nosebleeds) Leukopenia (increased susceptibility to infections and oral ulcerations) Hyperplastic gingivitis No: hepatosplenomegaly and lymphadenopathy
Slide 33-

Laboratory findings Anemia normocytic, normochromic Reticulocytopenia Leukopenia: granulocytopenia often < 1500/mm3 Thrombocytopenia: often < 30,000/mm3 Bone marrow: marked depression or absence hematopoietic cells and replacement by fatty tissue Normal chromosomal analysis
Slide 34-

Treatment Severe AA: Allogeneic BMT In the absence of availability of an HLA-matched sibling marrow donor - immunoablation ( ATG, cyclosporine, methylprednisolone, growth factors- G-CSF)
Slide 35-

Hemolytic anemia
Slide 36-

Corpuscular defects →Membrane defects →Enzyme defects →Hemoglobin defects →Congenital dyserythropoietic anemias Extracorpuscular defects →Immune →Nonimmune
Slide 37-

Clinical features suggesting a hemolytic process Ethnic factors: incidence of sickle gene factor in the black population (8%), high incidence of thalassemia in people of Mediterranean ancestry, high incidence of glucose-6-phosphate dehydrogenase deficiency among Sephardic Jews Age factors: anemia and jaundice in an Rh+ infant born to a mother Rh- or a group A or group B infant born to a group 0 mother History of anemia, jaundice, or gallstones in family Persistent or recurrent anemia associated with reticulocytosis Anemia unresponsive to hematinics Intermittent bouts or persistent indirect hyperbilirubinemia Splenomegaly Hemoglobinuria Presence of multiple gallstones
Slide 38-

Corpuscular hemolytic anemias Membrane defects Morphologic abnormalities: hereditary spherocytosis, elliptocytosis, stomatocytosis, acanthocytosis Spectrin is responsible for maintaining red cell shape, regulates the lateral mobility of integral membrane proteins and provides structural support for the lipid bilayer
Slide 39-

Hereditary spherocytosis Genetics Autosomal-dominant inheritance (75%), non-family history –25% Most common in people of northern European heritage Incidence of 1 in 5000 Pathogenesis Membrane instability due to dysfunction or deficiency of a red cell skeletal protein: ankyrin (75-90%) and/or spectrin (50%)
Slide 40-

The sequelae are as follow: Sequestration of red cells in the spleen (due to erythrocyte deformability) Depletion of membrane lipid Decrease of membrane surface area relative to volume, resulting in a decrease in surface area-to-volume ratio Tendency to spherocytosis Influx and efflux of sodium increased; cell dehydratation Increased glycolysis Premature red cell destruction
Slide 41-

Hematology Anemia mild to moderate; in erythroblastopenic crisis Hb may drop to 2 – 3g/dl MCV usually decreased, MCHC raised Reticulocytosis Blood film – microspherocytes, hyperdense cells , polychromasia Coomb’s test negative Increased red cell osmotic fragility – spherocytes lyse in higher concentrations of saline than normal red cells, occasionally only demonstrated after incubation of blood sample at 37 C for 24 hours Autohemolysis at 24 and 48 hours increased, corrected by the addition of glucose Reduced red cell survival Marrow- normoblastic hyperplasia, increased iron EMA-test
Slide 42-

Biochemistry Raised bilirubin, mainly indirect reacting Obstructive jaundice with increased direct-reacting bilirubin; may develop due to gallstones, a consequence of increased pigment excretion
Slide 43-

Clinical features Anemia and jaundice- severity depends on rate of hemolysis, degree of compensation of anemia by reticulocytosis, and ability of liver to conjugate and excrete indirect hyperbilirubinemia Splenomegaly Presents in newborn (50% of cases) with hyperbilirubinemia, reticulocytosis, normoblastosis, spherocytosis, negative Coomb’s test, and splenomegaly Presence before puberty in most patients Sometimes diagnosis made much later in life by chance
Slide 44-

Complications Hemolytic crisis – with pronounced jaundice due to accelerated hemolysis ( may be precipitated by infection) Erythroblastopenic crisis – dramatic fall in Hb level and reticulocyte count, usually associated with parvovirus B19 infection Folate deficiency caused by increased red cell turnover, may lead to superimposed megaloblastic anemia Gallstones in 50% of untreated patients, incidence increases with age Rarely hemochromatosis
Slide 45-

Treatment Folic acid supplement 1mg/day Leukocyte-depleted packed red cell transfusion for severe erythroblastopenic crisis Splenectomy for moderate to severe cases
Slide 46-

Hereditary elliptocytosis (HE) Is due to various defects in the skeletal proteins, spectrin and protein 4.1 , it results increased membrane rigidity and in decreased cellular deformability Autosomal-dominant mode of inheritance Elliptocytes varies from 50 to 90% Osmotic fragility normal or increased Treatment: transfusion, splenectomy, prophylactic folic acid
Slide 47-

Another types of membrane defects Hereditary stomatocytosis (the cells contain high Na and low K concentrations) Hereditary acanthocytosis Hereditary xerocytosis
Slide 48-

Enzyme defects Pyruvate Kinase deficiency: defective red cell glycolysis Red cell rigid, deformed and metabolically and physically vulnerable Autosomal –recessive inheritance Nonspherocytic hemolytic anemia Variable severity: moderate severe anemia Neonatal jaundice Splenomegaly Gallstones, hemosiderosis, bone changes Treatment: folic acid supplementation, transfusions, splenectomy
Slide 49-

Glucose-6-Phosphate Dehydrogenase deficiency Sex-linked recessive mode of inheritance Disease fully expressed in hemizygous males and homozygous females Most frequent among blacks and those of Mediterranean origin Associations : hemolysis may be produced by drugs, fava (broad) bean, infections
Slide 50-

Clinical features Drug induced hemolysis : -Analgetics and antipyretics -Antimalarian agents -Sulfonamides -Nitrofurans -Sulfones Favism: -acute life-threating hemolysis often leading to acute renal failure caused by ingestion of fava beans Associated with mediterranean and Canton varieties Neonatal jaundice Chronic nonspherocytic anemia Treatment: Avoid drugs deleterious in G6PD, splenectomy
Slide 51-

Hemoglobin defects →Thalassemias Alpha chains hemoglobinopathies: Deletion of two genes –alpha Thalassemia minor Beta chain hemoglobinopathies (Hgb S, C,E, D) Beta Thalassemia Major (impaired beta chain synthesis) →Sickle Cell Disease : Hgb SS disease, Hgb S-C disease, Hgb S-beta
Slide 52-

Sickle Cell Disease (SCD) Most common abnormal hemoglobin found in US (8% of the black population) at birth the incidence is 1 in 625 Genetics: transmitted as an incomplete autosomal-dominant trait Homozygotes ( two abnormal genes) do not synthetize Hb A, red cell contain 90-100% Hb S Heterozygotes (one abnormal gene) have red cell containing 20-40% Hb S
Slide 53-

Pathophysiology: A single amino acid substitution: valine for glutaminic acid ( in the beta-polypeptide chain) → Different electrophoretic mobility HbS is less soluble than HbA Sickle cells are prematurely destroyed causing a hemolytic anemia Sickle cells result in increased blood viscosity and impaired blood flow and initiate thrombi
Slide 54-

Clinical features Anemia- moderate to severe normochromic, normocytic Reticulocytosis Neutrophilia common Platelets often increased Blood smear: sickle cells, increased polychromasia, nucleated red cells, and target cells Erythrocyte sedimentation rate (ESR) – low Hemoglobin electrophoresis: HbS migrates slower than HbA, giving the diagnostic SS pattern
Slide 55-

Crises Vaso-oclusive or symptomatic crisis: - hand – foot syndrome (dactylitis) – hand-foot swelling - bone crises - osteonecrosis - CNS crises -thrombosis/ bleeding - pulmonary crises -dyspnea, severe hypoxemia - priapism - hematuria, - intrahepatic vasoocclusive crisis Splenic sequestration crisis due to of pooling large amount of blood in the spleen) – splenomegaly, abdominal pain of sudden onset Erythroblastopenic crisis (cessation of red cell production) Hyperhemolytic crisis, unusual, in association with certain drugs or acute infections
Slide 56-

Organ dysfunction Central nervous system (acute infarction of the brain) –motor disabilities, seizures, speech defects, deficit in IQ Cardiovascular system (cardiomegaly, myocardial dysfunction) Lungs (reduced PaO2, reduced saturation, increased pulmonary shunting, acute chest syndrome) Kidneys (increased renal flow, increased GFR, enlargement of kidneys, hypostenuria, proteinuria, nephrotic syndrome) Liver and biliary system (hepatomegaly, cholelithiasis) Bones (dactylisis, avascular necrosis)
Slide 57-

Eyes (retinopathy, angioid streaks, hyphema – blood in anterior chamber)) Ears ( sensorineural hearing loss) Adenotonsillar hypertrophy Skin (cutaneous ulcers of the legs) Genitourinary (priapism) Growth and development (by 2 –6 years of age the height and weight delayed) Delayed sex maturation Functional hyposplenism (progressive fibrosis) Hemostatic changes (hypercoagulable state)
Slide 58-

Diagnosis In utero: by PCR amplification of specific DNA sequences from fetal fibroblasts (obtained by amniocentesis) In newborn: electrophoresis for separation of hemoglobins Management Comprehensive care (prevention of complications) Prophylaxis of infections pneumococcal vacccine, H. Influenzae vaccines, early diagnosis of infections
Slide 59-

Treatment modalities Antisicking therapy : fetal hemoglobin production stimulating agents (5-Azacytidine, hydroxyurea, recombinant EPO, short-chain organic acids) Red cell HbS concentration reducing agents (calcium channel blockers) Membrane active agents Hemoglobin solubility increasing agents Bone marrow transplantation
Slide 60-

Thalassemias Beta-thalassemia – impaired beta-chain production Alpha-thalassemia – impaired alpha-chain production Genetic defects: Two genes for Beta-globin synthesis (one on each chromosome 11) B-thalassemias are due to point mutations in one or both genes Four genes for a- globin synthesis (two on each chromosome 16) Most a-thalassemias are due to deletion of one or more a-genes
Slide 61-

Hematology Hypochromic, microcytic anemia Reticulocytosis Leukopenia, thrombocytopenia Blood smear: target cells and nucleated cells, extreme anisocytosis, contracted red cells, polychromasia, punctate basophilia, circulating normoblasts HbF raised, HbA2 – increased Bone marrow: megaloblastic ( due to folate depletion), erythroid hyperplasia Decreased osmotic fragility High serum ferritin Biochemisty Raised bilirubin Evidence of liver dysfunction (late, as cirrhosis develops) Endocrine abnormalities (diabetes, hypogonadism)
Slide 62-

Clinical features Failure to thrive in early childhood Anemia Jaundice, usually slight, gallstones Hepatosplenomegaly, hypersplenism Abnormal facies: prominence of malar eminence, frontal bossing, depression of bridge of the nose, exposure of upper central teeth Skull radiographs showing hair-on-end appearance due to widening of diploid spaces Fractures due to marrow expansion and abnormal bone structure Osteoporosis Growth retardation, primary amenorrhea, delayed puberty in males Leg ulcers Skin bronzing If untreated, 80% of patients die in the first decade of life
Slide 63-

Complications Develop as a result of: - Chronic anemia - Chronic transfusion → hemosiderosis and hemochromatosis - Poor compliance with chelation therapy Endocrine disturbances: growth retardation, pituitary failure with impaired gonadotropins, IDDM, adrenal insufficiency, hypothyroidism Liver failure, cirrhosis cardiac failure due to iron myocardial iron overload Bony deformities due to extramedullary hematopoiesis Osteoporosis
Slide 64-

Management Transfusion therapy (when Hb falls <7g/dl) hypertransfusion program used to maintain a pretransfusion Hb between 10.5 – 11.0 g/dl - corrects the anemia and suppresses ineffective erythropoiesis Chelation therapy to maintain serum ferritin close to 1000 ng/ml Splenectomy to reduce the transfusion requirements Bone marrow transplantation Gene therapy in future Increase HbF synthesis (trials): 5-Azacytidine, hydroxyurea, cytosine arabinoside, busulfan, butyric acid analogues
Slide 65-

Supportive therapy: Folic acid Hepatitis B vaccination Treatment for congestive heart failure Endocrine invention Cholecystectomy Genetic counseling Management of osteoporosis (calcitonin, biphosphonates)
Slide 66-

Causes of death: Congestive heart failure Arrythmia Sepsis secondary to increased susceptibility to infection post splenectomy Multiple organ failure due to hemochromatosis
Slide 67-

Extracorpuscular hemolytic anemias Immune hemolytic anemia Warm autoimmune hemolytic anemia - responsible antibodies IgG class Cold autoimmune hemolytic anemia –IgM antibodies are cold agglutinins, and cold hemagglutinin disease, cold hemagglutinin disease usually occurs during Mycoplasma pneumoniae infection Nonimmune hemolytic anemia Microangiopathic hemolytic anemia caused by renal, cardiac, liver disease, infections.