Red cell Disorder

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4. HISTORYHISTORY
Thalassemia First described by Dr ThomasThalassemia First described by Dr Thomas
Cooley in 1925.Cooley in 1925.
He observed the disorder in patients ofHe observed the disorder in patients of
mediteranean ancestry, and called “Cooley'smediteranean ancestry, and called “Cooley's
anemia”. •anemia”. •
Doctors at the University of RochesterDoctors at the University of Rochester
"Whipple and Bradford”"Whipple and Bradford” proposedproposed the namethe name
Thalassemia.Thalassemia.

5. OVERVIEWOVERVIEW
• The name is derived from the Greek word “Thalasso =The name is derived from the Greek word “Thalasso =
Sea” and “Hemia = Blood” in reference to anemia ofSea” and “Hemia = Blood” in reference to anemia of
the sea. History of Thalassemiathe sea. History of Thalassemia
• THALASSEMIA is a heterogenous group of disordersTHALASSEMIA is a heterogenous group of disorders
characterized bycharacterized by genetically determined reduction ingenetically determined reduction in
the rate ofthe rate of synthesissynthesis ofof normalnormal globin chain.globin chain.
• Commonest form of haemoglobinopathyCommonest form of haemoglobinopathy..

6. PREVALENCEPREVALENCE
• The alpha thalassemia is prevalent in southeast Asia,The alpha thalassemia is prevalent in southeast Asia,
Malaysia and southern china.Malaysia and southern china.
• The beta thalassemia are seen primarily in the areaThe beta thalassemia are seen primarily in the area
surrounding Mediterranean sea, Africa and southeastsurrounding Mediterranean sea, Africa and southeast
Asia.Asia.
• Carrier frequency of thalassemia in India is about 3 %Carrier frequency of thalassemia in India is about 3 %
and estimated frequency of thalassemia at birth isand estimated frequency of thalassemia at birth is
1:2700.1:2700.

7. •Thalassemia is found in
parts of the world where
malaria is common.
•It occurs most frequently in
people from :
 Mediterranean countries
 North Africa
The Middle East
India
Central & Southeast
Asia.
Geographical Distribution

8. GENETICSGENETICS
• Thalassemia are autosomal recessive disorders.Thalassemia are autosomal recessive disorders.
• Globin of haemoglobin A is made up of 2 alpha and 2Globin of haemoglobin A is made up of 2 alpha and 2
beta chains, synthesis of alpha chains is controlled by 2beta chains, synthesis of alpha chains is controlled by 2
gene clusters on chromosome 16 and of beta chains ongene clusters on chromosome 16 and of beta chains on
chromosome 11.chromosome 11.

9. Hb A - 97% HbA2 – 1.5-3.5% HbF - <1%

10. STEPS IN SYNTHESIS OF GLOBIN CHAINSTEPS IN SYNTHESIS OF GLOBIN CHAIN

12. CLASSIFICATION OF THALASSEMIACLASSIFICATION OF THALASSEMIA
• According to the deficient globin chainAccording to the deficient globin chain
• Alpha thalassemiaAlpha thalassemia
• Beta thalassemiaBeta thalassemia
• Delta-beta thalassemiaDelta-beta thalassemia
• Gamma delta beta thalassemiaGamma delta beta thalassemia

13. According to clinical severity -According to clinical severity -
Alpha thalassemiaAlpha thalassemia
• Silent carrierSilent carrier
• Thalassemia traitThalassemia trait
• HbH diseaseHbH disease
• Hb Barts/Hydrops foetalis syndromeHb Barts/Hydrops foetalis syndrome
Beta thalassemiaBeta thalassemia
• Thalassemia majorThalassemia major
• Thalassemia intermediaThalassemia intermedia
• Thalassemia minorThalassemia minor

14. ALPHA THALASSEMIA
α
α α
α
αα/αα
αα/-α
αα/--
Normal
--/-α
--/--
Silent carrier
Thalassemia trait/minor
HbH disease
Hb Barts
Hydrops foetalis syndrome

15. ΑΑLPHALPHA THALASSEMIATHALASSEMIA
• αα chains of globin are not/partly synthesized.chains of globin are not/partly synthesized.
• It is required for both HbA and HbF .It is required for both HbA and HbF .
• Majority ofMajority of αα thalassemia cases result fromthalassemia cases result from genegene
deletions.deletions.
• Others –Others –
1)1) Mutation which cause aberrant splicingMutation which cause aberrant splicing
2)2) Mutation of chain terminator codonMutation of chain terminator codon
3)3) Mutation which cause instability ofMutation which cause instability of αα globin chain after translation.globin chain after translation.

16. CLINICAL
CLASSIFICATION
GENOTYPE NO. OF GENES
PRESENT
Silent carrier αα/- α 3 genes
α thalassemia trait - α/- α or αα/- - 2 genes
Hemoglobin H disease -α/- - 1 gene
Hb Barts / Hydrops
fetalis
- -/- - 0 genes
ALPHA THALASSEMIA -
CLASSIFICATION

18. Redused biosynthesis of alpha chain
Beta and gamma chain produced
ϒ tetramer, α absent
Unable to carry and deliver oxygen
Intra uterine
hypoxia
Foetal death
Still birth
Formation of beta tetramer, present in
developing normoblast
Moderatly ineffective
erythropoiesis
Hb H inclusion in red cells,
cannot dissociate oxygen in
tissue
Spleen trap this cells
Hemolytic anemia
Tissue
hypoxia
Pathophysiology in alpha
thalassemia

20. HB BARTS’ HYDROPS FOETALIS SYNDROMEHB BARTS’ HYDROPS FOETALIS SYNDROME
• Deletion of all 4 genes.Deletion of all 4 genes.
• Intrauterine death of such a baby or if born, diesIntrauterine death of such a baby or if born, dies
wihin first 2 hour.wihin first 2 hour.
• Hb barts’ ( freeHb barts’ ( free ϒϒ 4 chains ) has high affinity for4 chains ) has high affinity for
oxygen and therefore , oxygen does not dissociateoxygen and therefore , oxygen does not dissociate
fromfrom ϒϒ 4 resulting in sever tissue hypoxia and4 resulting in sever tissue hypoxia and
foetal death.foetal death.

21. HB BARTS’ HYDROPS FOETALISHB BARTS’ HYDROPS FOETALIS
SYNDROMESYNDROME
Hepatosplenomegaly

22. HB BARTS’ HYDROPS FOETALIS SYNDROMEHB BARTS’ HYDROPS FOETALIS SYNDROME
Peripheral smear

23. HB H DISEASEHB H DISEASE
• --/-alpha--/-alpha
• Anemia, Hb 6-10gm/dlAnemia, Hb 6-10gm/dl
• Reticulocyte count 4 - 15 %Reticulocyte count 4 - 15 %
• Icterus and hepatosplenomegalyIcterus and hepatosplenomegaly
• Lab findingsLab findings
• AnisopoikilocytosisAnisopoikilocytosis
• HypochromiaHypochromia
• MicrocytosisMicrocytosis
• Target cellsTarget cells
• Inclusions bodiesInclusions bodies
• Hb elctrophoresis demonstrates fast moving HbH band in theHb elctrophoresis demonstrates fast moving HbH band in the
range of 5-35 %.range of 5-35 %.
• HbH also demonstrate on HPLC.HbH also demonstrate on HPLC.

25. HbH Inclusion Bodies

26. ΑΑ-THAASSEMIA TRAIT:-THAASSEMIA TRAIT:
Deletion of twoDeletion of two αα globin genes (-globin genes (- αα/-/- αα oror --/--/ α αα α).).
• Clinically normalClinically normal
• Hb 9-12 g/dlHb 9-12 g/dl
• MCV ↓MCV ↓
• MCH ↓MCH ↓
• Mild microcytosis and hypochromiaMild microcytosis and hypochromia
Hb electrophoreisis normalHb electrophoreisis normalHbH Hb bart : not demonstrableHbH Hb bart : not demonstrable
They are often mistakenly diagnosed as having iron deficiency anaemia.They are often mistakenly diagnosed as having iron deficiency anaemia.
( RDW is useful marker)( RDW is useful marker)

27. SILENT CARRIERSILENT CARRIER
Deletion of oneDeletion of one αα globin gene (-globin gene (- αα// α αα α))
People with this condition are usually haematologically andPeople with this condition are usually haematologically and
clinically normalclinically normal..
• Confirmation by DNA analysis.Confirmation by DNA analysis.

28. MOLECULAR BASIS OF BETAMOLECULAR BASIS OF BETA
THALASSEMIASTHALASSEMIAS
• Beta0 thalassemiasBeta0 thalassemias
• Complete absence of beta chain synthesisComplete absence of beta chain synthesis
• Beta+ thalassemiasBeta+ thalassemias
• Reduced synthesisReduced synthesis

29. ΒΒ THALASSEMIATHALASSEMIA
β
β
βN
/βN
β0
/βN
β+
/βN
Normal
β+
/β+
Thalassemia minor
Thalassemia minor
Thalassemia intermedia

30. ΒΒ THALASSAEMIATHALASSAEMIA
β
β
βN
/βN
β0
/β0
β0
/β+
Normal
Thalassemia Major
Thalassemia Major

31. MUTATIONS CAUSINGMUTATIONS CAUSING ΒΒ THALASSEMIATHALASSEMIA

32. MUTATIONS FREQUENTLY OBSERVEDMUTATIONS FREQUENTLY OBSERVED
IN INDIANS ININ INDIANS IN ΒΒ THALASSAEMIATHALASSAEMIA
• Intron 1 position 5 (G-C)Intron 1 position 5 (G-C)
• 619 base pair deletion619 base pair deletion
• Intron 1 position 1 (G-T)Intron 1 position 1 (G-T)
• Frame shift mutation in codon 41 – 42 (-CTTT)Frame shift mutation in codon 41 – 42 (-CTTT)
• Codon 15 (G-A)Codon 15 (G-A)

34. THALASSEMIA MAJORTHALASSEMIA MAJOR
• Beta thalassemia major was first described by a DetroitBeta thalassemia major was first described by a Detroit
pediatrician,pediatrician, Thomas CooleyThomas Cooley, in 1925., in 1925.
• Also known as Cooley's anemiaAlso known as Cooley's anemia
• It is the homozygous form ofIt is the homozygous form of ββ 0 /0 / ββ 0 or0 or ββ + /+ /ββ + or+ or
double heterozygousdouble heterozygous ββ 0 /0 / ββ +.+.
• Infant areInfant are well at birthwell at birth but develop moderate to severbut develop moderate to sever
anemia, failure to thrive, hepatosplenomegaly and boneanemia, failure to thrive, hepatosplenomegaly and bone
changes which are prominent in face.changes which are prominent in face.

35. PATHOPHYSIOLOGY OFPATHOPHYSIOLOGY OF ΒΒ THALASSEMIATHALASSEMIA
MAJORMAJOR
• Accumulation of free alpha chainsAccumulation of free alpha chains
• Extravascular hemolysisExtravascular hemolysis
• Marrow and bone changesMarrow and bone changes
• Extramedullary hemopoiesisExtramedullary hemopoiesis
• Synthesis of HbFSynthesis of HbF
• Iron overloadIron overload

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38. CLINICAL FEATURESCLINICAL FEATURES
• AGE :AGE :
1)1)Present within first year of life, at birth asymptomatic and after 3Present within first year of life, at birth asymptomatic and after 3
month anemia develops.month anemia develops.
2)2)Infant may present with failure to thrive, intermittent infectionsInfant may present with failure to thrive, intermittent infections
and poor feeding.and poor feeding.
• PALLOR ( progressive increase )PALLOR ( progressive increase )
• SPLENOMEGALY ( Hemosiderosis and hyperfunction ofSPLENOMEGALY ( Hemosiderosis and hyperfunction of
spleen)spleen)

40. β-Thalassemia facial bone abnormalities.
These changes include bossing of the
skull; hypertrophy of the maxilla, exposing the
upper teeth; depression of nasal bridge; and
periorbital puffiness
β-Thalassemia major. Note the pallor, short
stature, massive hepatosplenomegaly,
and wasted limbs in this undertransfused case
of β-thalassemia major

41. BETA THALASSEMIA MAJORBETA THALASSEMIA MAJOR

42. BETA THALASSEMIA MAJORBETA THALASSEMIA MAJOR
• Growth is retarded and delayed puberty.Growth is retarded and delayed puberty.
• Increase susceptibility to infections.Increase susceptibility to infections.
• CARDIAC CHANGES : Myocardial hemosiderosis developsCARDIAC CHANGES : Myocardial hemosiderosis develops
especially in transfused patients.especially in transfused patients.

43. BETA THALASSEMIA MAJORBETA THALASSEMIA MAJOR
• HEPATOMEGALY : Mainly first 3 to 4 year..HEPATOMEGALY : Mainly first 3 to 4 year..
• ENDOCRINE SYSTEM :ENDOCRINE SYSTEM :
1)1)Growth hormone deficiencyGrowth hormone deficiency
2)2)HypothyrodismHypothyrodism
3)3)HypoparathyrodismHypoparathyrodism
4)4)Diabetes mellitusDiabetes mellitus

44. PERIPHERAL SMEAR INDICESPERIPHERAL SMEAR INDICES
• Microcytic hypochromicMicrocytic hypochromic
anemia , basophilic stippling ,anemia , basophilic stippling ,
marked anisopoikilocytosis ,marked anisopoikilocytosis ,
Target cellsTarget cells
• Reticulocyte count;mildlyReticulocyte count;mildly
increasedincreased
• Leucocyte ;increased ,Leucocyte ;increased ,
Platelet ;normalPlatelet ;normal
• Hb 3- 8 g/dlHb 3- 8 g/dl
• MCV= <70flMCV= <70fl
• MCHC=(22to 30g/dl)MCHC=(22to 30g/dl)
• MCH=(20 -28pg)MCH=(20 -28pg)
• S.iron( >200µg/dl), s.ferritinS.iron( >200µg/dl), s.ferritin
–markedly increased–markedly increased
• Transferrin saturationTransferrin saturation
increased, TIBC –Normal orincreased, TIBC –Normal or
redusedredused

46. • Thalassemias
• Smear Characteristics
– Hypochromia
– Microcytosis
– Target Cells
– Tear Drops

49. BONE MARROWBONE MARROW
• HypercellularHypercellular
• Erythroid hyperplasia is markedErythroid hyperplasia is marked
• Erythropoisis is normoblasticErythropoisis is normoblastic
• M:E ratio 1:5M:E ratio 1:5
• Myelopoisis and megakaryopoisis are normalMyelopoisis and megakaryopoisis are normal
• Bone marrow iron increasedBone marrow iron increased

50. THE BONE MARROW HAS INCREASED NUMBERS OFTHE BONE MARROW HAS INCREASED NUMBERS OF
ERYTHROID PRECURSORS (A LOW MYELOID TO ERYTHROIDERYTHROID PRECURSORS (A LOW MYELOID TO ERYTHROID
RATIO) RELATED TO THE INCREASED PERIPHERAL RBCRATIO) RELATED TO THE INCREASED PERIPHERAL RBC
DESTRUCTION IN THIS DISEASE.DESTRUCTION IN THIS DISEASE.
Bone marrow Aspirate

51. THE BONE MARROW HAS INCREASED NUMBERS OF ERYTHROIDTHE BONE MARROW HAS INCREASED NUMBERS OF ERYTHROID
PRECURSORS (A LOW MYELOID TO ERYTHROID RATIO) RELATED TO THEPRECURSORS (A LOW MYELOID TO ERYTHROID RATIO) RELATED TO THE
INCREASED PERIPHERAL RBC DESTRUCTION IN THIS DISEASE.INCREASED PERIPHERAL RBC DESTRUCTION IN THIS DISEASE.
Bone marrow Biopsy

52. SPECIAL LABORATORY TEST FORSPECIAL LABORATORY TEST FOR
DIAGNOSISDIAGNOSIS
• Hb F ↑ : the levels are higher inHb F ↑ : the levels are higher in ββ zero then inzero then in ββ plus thalassemia.plus thalassemia.
There are various method method for estimation of HbF.There are various method method for estimation of HbF.
• The commonly used method isThe commonly used method is Betke methodBetke method :: aa. Principle. Principle :: FetalFetal
hemoglobin (HbF) is more resistant to denaturation in acidichemoglobin (HbF) is more resistant to denaturation in acidic
solution than adult hemoglobin (HbA). Alkali converts HbA tosolution than adult hemoglobin (HbA). Alkali converts HbA to
alkaline hematin. Alkaline hematin is insoluble and precipitates.alkaline hematin. Alkaline hematin is insoluble and precipitates.
• HbF is quantitated by measuring the hemoglobin concentrationHbF is quantitated by measuring the hemoglobin concentration
before and after denaturation.before and after denaturation.

53. • Used to detect the presence of Hb F (fetal hemoglobin).Used to detect the presence of Hb F (fetal hemoglobin).
• RBCS on a slide are stained to detect the presence of Hb F.RBCS on a slide are stained to detect the presence of Hb F.
• Can distinguish heterocellular HbF from pancellular HbF seen inCan distinguish heterocellular HbF from pancellular HbF seen in
HPFH.HPFH.
• Rarely done and difficult to interpret and standardize due toRarely done and difficult to interpret and standardize due to
significant variability between observers.significant variability between observers.
• Confirms maternal blood contamination with fetal blood in casesConfirms maternal blood contamination with fetal blood in cases
of fetomaternal hemorrhage, with D mismatch.of fetomaternal hemorrhage, with D mismatch.
• Flow cytometry is now the primary tool for investigation of fetalFlow cytometry is now the primary tool for investigation of fetal
haemoglobins in Australia.haemoglobins in Australia.
Kleihauer Betke test For Hb F

54. Kleihauer Betke test. This peripheral blood from a postpartum woman
with fetomaternal hemorrhage demonstrates HbF containing fetal cells (dark red) in a
background of maternal cells (ghost-like cells).

55. ELECTROPHORESIS PRINCIPLE.ELECTROPHORESIS PRINCIPLE.
• Separation of haemoglobins with electrophoresis atSeparation of haemoglobins with electrophoresis at
pH 8.4 (alkaline) and pH 6.2 (acid).pH 8.4 (alkaline) and pH 6.2 (acid).
• Scanning allows quantification of the hemoglobinScanning allows quantification of the hemoglobin
present, bands are seen by staining.present, bands are seen by staining.

56. GEL ELECTROPHORESISGEL ELECTROPHORESIS
Alkaline pH
Acidic pH

57. (1) Normal (2) New born (3) Hb C trait [A-C] (4) Hb SC disease [S-C] (5) Sickle cell disease [S-
S], (6) Sickle cell trait [A – S] (7) New born (8) Normal.

58. Gel electrophoresis instrument

60. DNA ANALYSIS.DNA ANALYSIS.
• Indicated when the hemoglobinopathy not confirmed
by other methods or when the underlying mutation
important to management.
• These are of value in predicting the severity ofThese are of value in predicting the severity of
disease.disease..
• For genetic counseling defining the particular
mutation or deletion is often required – this is
achieved by a variety of molecular techniques.

61. GLOBIN CHAIN SYNTHESISGLOBIN CHAIN SYNTHESIS
• It is helpful when electrophoretic and other usualIt is helpful when electrophoretic and other usual
haematological studies fail to diagnose.haematological studies fail to diagnose.
• It demonstrateIt demonstrate αα :: ββ ratio. Normal ratio is about 1.0.ratio. Normal ratio is about 1.0.
• It is reduced in alpha thalassemia and increased in betaIt is reduced in alpha thalassemia and increased in beta
thalassemiathalassemia

62. THALASSEMIATHALASSEMIA INTERMEDIAINTERMEDIA
• Clinical spectrum between thalassemia trait andClinical spectrum between thalassemia trait and
thalassemia major.thalassemia major.
• This include cases of interaction ofThis include cases of interaction of ββ,,αα, Hb E, Hb, Hb E, Hb
D and Hb S genes.D and Hb S genes.
• Present in the later age ( 2-5 yr )Present in the later age ( 2-5 yr )

63. CLINICAL FEATURESCLINICAL FEATURES
• Mild to moderate anemiaMild to moderate anemia
• Mild to moderate splenomegalyMild to moderate splenomegaly
• Mild skeletal and facial changes.Mild skeletal and facial changes.
• Iron overloadIron overload
• Recurrent leg ulcerRecurrent leg ulcer
• Repeated infectionRepeated infection
Thalassemia Intermedia

64. Thalassemia intermedia
• Mild degree of anemiaMild degree of anemia
• Red cell count isRed cell count is
increasedincreased
• MCV<70 flMCV<70 fl
• MCH<25 pgMCH<25 pg
• MCHC is reducedMCHC is reduced
• Hb 6- 9 gm/dlHb 6- 9 gm/dl
• Reticulocyte count ( 2-5%) and S.Reticulocyte count ( 2-5%) and S.
bilirubin are slightly raisedbilirubin are slightly raised
• HbF 10-30%, H bA2 < 4%HbF 10-30%, H bA2 < 4%
• Moderate degree ofModerate degree of
anisopoikilocytosis,anisopoikilocytosis,
microcytic hypochromic,microcytic hypochromic,
target cells,target cells,
basophilic stipplingbasophilic stippling

65. MODERATE DEGREE OFMODERATE DEGREE OF
ANISOPOIKILOCYTOSIS,ANISOPOIKILOCYTOSIS,
MICROCYTICMICROCYTIC
HYPOCHROMIC,HYPOCHROMIC,
TARGET CELLS,TARGET CELLS,

66. THALASSEMIA MINORTHALASSEMIA MINOR
• Heterozygous carrier state characterized by little orHeterozygous carrier state characterized by little or
no anemia but prominent morphological changesno anemia but prominent morphological changes
of red cellsof red cells

67. BETA THALASSEMIA MINORBETA THALASSEMIA MINOR
• Mild degree of anemiaMild degree of anemia
• Red cell count is incrasedRed cell count is incrased
• MCV<70 flMCV<70 fl
• MCH<25 pgMCH<25 pg
• MCHC is normalMCHC is normal
• Hb >9.0 gm/dlHb >9.0 gm/dl
• Reticulocyte count and S. bilirubin are slightly raisedReticulocyte count and S. bilirubin are slightly raised

68. BETA THALASSEMIA MINORBETA THALASSEMIA MINOR
MICROCYTOSISMICROCYTOSIS
HYPOCHROMIAHYPOCHROMIA
ANISOPOIKILOCYTANISOPOIKILOCYT
O-SISO-SIS
TEAR DROP CELLTEAR DROP CELL
TARGET CELLTARGET CELL

69. BETA THALASSEMIA MINORBETA THALASSEMIA MINOR
• Bone marrow is cellular with erythroid hyperplasia.Bone marrow is cellular with erythroid hyperplasia.
• Osmotic fragility test shows resistance to hemolysis.Osmotic fragility test shows resistance to hemolysis.
• Elevation of HbA2.Elevation of HbA2.
• HbF may be mildly increasedHbF may be mildly increased

70. MENTZER INDEX(M.I)MENTZER INDEX(M.I)
M.I =M.I =
<13 SEEN IN THALASSEMIA<13 SEEN IN THALASSEMIA
ANDAND
>13 IN IRON DEFICIENCY ANEMIA>13 IN IRON DEFICIENCY ANEMIA
MCV (fl)
RED CELL COUNT
(millions/ul)

71. MISCELLENEOUS THALASSEMICMISCELLENEOUS THALASSEMIC
SYNDROMESYNDROME
• Hb S – ThalassaemiaHb S – Thalassaemia
• Hb E – ThalassaemiaHb E – Thalassaemia
• Hb D – ThalassaemiaHb D – Thalassaemia
• HPFH – Hereditary persistence of foetal hemoglobinHPFH – Hereditary persistence of foetal hemoglobin

72. SICKLE CELL BETA THALASSEMIASICKLE CELL BETA THALASSEMIA
• Also k/a Micro drepanocytic diseaseAlso k/a Micro drepanocytic disease
• Two formsTwo forms
• Sickle cell Beta 0 thalassemiaSickle cell Beta 0 thalassemia
• Sickle cell Beta + thalassemiaSickle cell Beta + thalassemia

73. PREVENTIONPREVENTION
• Health educationHealth education
• Carrier screening and genetic counsellingCarrier screening and genetic counselling
• Prenatal diagnosis.Prenatal diagnosis.
Commonly employed method for screening :Commonly employed method for screening :
• Red cell indicesRed cell indices
• Single tube osmotic fragility testSingle tube osmotic fragility test
• Estimation of Hb A2Estimation of Hb A2
• Haemoglobin electrophoresis at alkaline pHHaemoglobin electrophoresis at alkaline pH
• Estimation of Hb F and Hb H inclusion.Estimation of Hb F and Hb H inclusion.

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