Anemia apotheken umschau

One speaks of anemia with a lack of red blood pigment (hemoglobin) and/or red blood corpuscles (erythrocytes) and thus a too small portion of blood cells (hematocrit) in the body. For the diagnosis of anemia, these are the decisive parameters.

Important to know: The number of red blood cells does not always correlate with the red blood pigment. Thus, the red blood cell count may still be normal or even increased, although there is already a decrease in red blood pigment.

This is how the blood is composed

More than half of the blood consists of blood plasma. Numerous substances are dissolved in the cartilage – from hormones and other messenger substances to nutrients (proteins, salts and sugar). With the blood these substances finally reach all regions of the body and supply there the organs and the fabric.

The other half of the blood consists of cells. This part is measured by the hematocrit value. These cells are divided into three major groups: white blood cells (leukocytes) are part of the body's defense system and protect the body from infection; platelets (thrombocytes) are involved in hemostasis; and red blood cells (erythrocytes) carry oxygen around the body.

The vast majority of the cells in the blood consist of red blood cells. They perform one of the most important functions of the blood system: transporting oxygen and carbon dioxide. Essential to this task is a molecule called hemoglobin, which is found in erythrocytes and is responsible for the red color of the blood.

Oxygen binds to certain regions of this molecule, which enters the blood in the lungs. Hemoglobin transports it through the body and finally delivers it to the organs and ties where it is needed. In the exchange, the metabolic product carbon dioxide (CO2) binds to the hemoglobin. Carbon dioxide is thus transported back to the lungs and exhaled.

If there are too few red blood cells or if there is too little hemoglobin in the body, the organs do not receive enough oxygen. This can cause discomfort – although those affected experience the symptoms differently, either weakly or strongly. Not always all symptoms must be present.

The classic symptoms of anemia include:

– shortness of breath to heart palpitations under stress.

The often described pallor of the skin is a rather unspecific sign. It occurs because the blood vessels constrict in response to the lack of oxygen. You can read more about the possible signs of different forms of anemia below in the section "Symptoms of anemia".

The family doctor can detect anemia with the help of a simple blood draw. If anemia is present, it is important to determine the causes so that appropriate measures can be taken. Depending on the cause and severity, a change in diet, medication or medical intervention (for example, to eliminate a source of bleeding) may be necessary. In the case of very pronounced anemia symptoms, it may also be necessary to supply the missing amount of red blood cells via a blood transfusion. Normally, there is a balance between blood formation. blood breakdown and blood loss, respectively. In anemia, this balance is disturbed. The causes of anemia can be multiple and also combined. In addition to impaired hematopoiesis, increased blood loss or degradation may occur at the same time.

Classification of anemia forms:

Impaired hematopoiesisPossible causes are changes in the stem cell in the bone marrow, from which all other blood cells are formed, or a displacement of healthy blood formation by diseases of the bone marrow. Other causes can be a deficiency of iron, vitamin B12 or folic acid, as well as (chronic) kidney disease, as a result of which too little of the hormone erythropoietin is produced. Erythropoietin normally gives the signal to the bone marrow to produce blood cells. 90% formed in the kidneys after birth. Increased breakdown or loss of red blood cells: Possible causes are acute or chronic bleeding, enlargement of the spleen (the usual site of breakdown of red blood cells), but also increased decay of erythrocytes (hemolysis), for example, due to infectious diseases, metabolic disorders or drugs. Anemia apotheken umschau

1) Disturbed blood formation

Red blood cells only live for about four months. Therefore, the body constantly produces new erythrocytes in the bone marrow, which begin their work in the blood after about seven days of development in the bone marrow. This is when red blood cells and all other cell types are formed from an original cell. It has the ability to mature into the different types of cells as needed (pluripotent stem cell).

If these stem cells are diseased or displaced by diseases that require space in the bone marrow, not enough functional red blood cells can be formed. In addition, certain nutrients are necessary so that the erythrocytes can be formed and mature in the bone marrow. The most important of these are iron, folic acid and vitamin B12.

Stem cell disease and bone marrow involvement: Stem cell diseases are very rare causes of anemia. These include, for example, aplastic anemia (AA), myelodysplastic syndrome (MDS), paroxysmal nocturnal hemoglobinuria (PNH) and congenital dysplastic anemia. The displacement of blood formation by tumors growing in the bone marrow or in leukemias or lymphomas is also very rare compared to the other causes of anemia, but it shows how significant it is to find out the cause of anemia. Folic acid and vitamin B12 (cobalamin) deficiency: Folic acid is found, for example, in yeast, liver, green leafy vegetables, broccoli, asparagus, carrots, beet, nuts, whole grains or egg yolks. The recommended daily requirement is 300 micrograms. For women of childbearing potential, pregnant and lactating women, the recommended daily intake is 500 micrograms. In addition, the need for folic acid is increased in the case of chronic inflammatory or malignant diseases or in the case of an increased blood formation rate. Folic acid is absorbed in the human body through the small intestine and stored in the liver. The amount of folic acid stored in the liver (approx. 5 mg) is sufficient for almost three months in the absence of intake. Vitamin B12 is found primarily in animal foods (meat, fish, milk and eggs) and in small amounts in plant products (e.g. sauerkraut). In the intestine of humans microorganisms are settled, which produce there vitamin B12. However, the vitamin B12 produced by microorganisms in the human intestine cannot be absorbed. Humans are therefore dependent on a sufficient supply through the diet. Moreover, vitamin B12 can only be absorbed in the functional form via the small intestine if the so-called intrinsic factor (IF) is formed in the stomach. In case of insufficient formation, the vitamin B12 is digested. Loses its function. The daily requirement of vitamin B12 is 5 micrograms. The amount of vitamin B12 stored in the liver is sufficient for about one to two years.

In summary, folic acid and vitamin B12 are necessary for the formation of the building blocks that encode the genetic material of living beings (DNA). If one of the two substances is lacking, fewer red blood cells are formed because DNA production is disturbed. The red blood cells formed are larger than usual due to this disorder.

Iron deficiency: Iron is found not only in animal foods (meat, offal such as liver or kidneys, chicken egg yolk) but also in legumes, brewer's yeast, parsley and cereals. Iron is indispensable for blood formation in the human organism and is an essential component of hemoglobin, the molecule in red blood cells that binds oxygen. If there is not enough iron, although there is a sufficient number of red blood cells. However, these then contain so little hemoglobin that they can only carry oxygen to a limited extent and are smaller than usual. Daily iron loss is 1 mg in men, 2 mg in women of childbearing age and 3 mg in pregnant women.

Iron deficiency is by far the most common cause of anemia. Worldwide, about 25 percent of people suffer from iron deficiency, and about 80 percent of all anemias are due to iron deficiency. Often, those affected simply do not consume enough in their diet. Especially in phases with increased iron requirements (sports, pregnancy, breastfeeding and in growing children), it is therefore important to ensure a sufficient supply. At risk are vegetarians, patients with nutritional disorders or intestinal diseases. The recommended daily dietary iron intake is 12 mg for men, 15 mg for women of childbearing age and 30 mg for pregnant women. Bleeding, especially menstrual bleeding that is too heavy and lasts too long, can also be a reason for iron deficiency. Because while iron is lost with the blood, a lot of it is needed at the same time for the formation of new erythrocytes. Much less frequently, an iron deficiency is caused by a reduced absorption of the trace element in the intestine – in the case of various intestinal diseases such as celiac disease/sprue, chronic inflammatory bowel diseases or after partial gastric resection.

2) Shortened survival time or loss of red blood cells

Possible causes of increased degradation or loss of red blood cells are acute and chronic bleeding, enlargement of the spleen (the usual site of degradation of red blood cells), but also increased decay of erythrocytes (hemolysis).

bleeding: When we bleed, the body loses blood including its components such as erythrocytes, hemoglobin and iron. In the case of small bleedings, such as a prick on the thorn of a rose or a graze, it is not a big deal because the amounts are small. The body can compensate by absorbing more fluid into the vascular system in the short term, releasing iron from its storage reserves and stimulating the production of new erythrocytes. The situation is different in cases of prolonged and/or more severe bleeding, such as those resulting from surgery or severe accidents. Even in the case of more inconspicuous but long-lasting bleeding – for example, from a stomach ulcer or, in women, from unusually heavy menstrual bleeding – such large amounts of blood can be lost that the body can no longer compensate for the losses, resulting in anemia.
Enlargement of the spleen (splenomegaly): The spleen filters out dead, defective or deformed erythrocytes from the blood and breaks them down. In this way, it ensures that only healthy, functional red blood cells remain in circulation. An enlargement of the spleen or erythrocytes that have changed in shape can cause too many blood cells to be removed in this way, resulting in anemia.
Shortens red blood cell survival with increased degradation (hemolysis): Certain defects of the erythrocytes can cause the survival time of the red blood cells to be shortened and they die or burst earlier (hemolyze). This group includes, for example, spherocytosis, glucose-6-phosphate dehydrogenase deficiency (= favism) or disorders in the formation of red blood pigment (e.g. thalassemia, sickle cell disease). In addition, autoimmune hemolytic anemia (AIHA) can lead to the breakdown of red blood cells. Antibodies (heat autoantibodies, cold autoantibodies) are formed that are directed against the patient's own red blood cells and destroy them. In addition, increased blood loss can occur with red blood cell damage. This can happen by mechanical means, for example, an artificial heart valve, by thermal means in a burn, by chemical means, for example, snake venom, arsenic, lead and copper. Other possible causes are changes in the smallest vessels (hemolytic uremic syndrome (HUS), thrombotic thrombocytopenic purpura (TTP)), various infectious diseases (e.g., malaria), and drugs.

Other causes of anemia

Anemia in chronic diseases/infectious anemia is the second most common form of anemia after iron deficiency anemia. This form of anemia develops in the case of a chronic disease – for example, in the case of prolonged inflammations and infections such as tuberculosis, in the case of diabetes mellitus, but also in the case of malignant diseases and autoimmune diseases. A clear assignment to formation or degradation disorder is often not possible here. The symptoms of the underlying disease are in the foreground in this anemia. Are aggravated by general symptoms of anemia.

Symptoms of anemia

If there are not enough red blood cells in the circulatory system, the patient may feel tired and listless. It happens that the skin loses color and a pallor develops. As described, however, the paleness of the skin is a rather uncertain sign of anemia. Concentration may also be impaired, and the affected person may also feel dizzy during exertion. Some patients complain of a ringing or throbbing in the ears or freeze rapidly.

If the extent of anemia is greater, the heartbeat may accelerate (tachycardia). The pulse becomes weaker, there are sweating, dizziness and possibly even shortness of breath and fainting spells. Particularly in patients with pre-damaged hearts, the lack of oxygen supply to the pump organ can cause. The increased stress caused by the increased heartbeat leading to a heart attack.

Blood loss is sometimes gradual. If small amounts of blood are lost over a longer period of time, anemia may develop without the affected person noticing anything. The body compensates for the slow loss. Up to two thirds of the blood cells can be lost gradually without the patient noticing anything more than a little tiredness and fatigue.

Such blood loss can still be dangerous – therefore, if you experience frequent weakness and persistent fatigue, you should consult a doctor and have possible causes clarified.

Symptoms of iron deficiency
Iron deficiency is the most common cause of anemia. In addition to the above anemia symptoms, there are signs that indicate that the body is deficient in this important trace element: cracks may form at the corners of the mouth (perlèche, lazy spots). Fingernails become more brittle. Get grooves eventually. Hair falls out more easily. Painful inflammations (aphthae) may occur repeatedly in the oral mucosa. The mucosa of the mouth, tongue and esophagus may also suffer, resulting in pain when swallowing and a burning tongue (Plummer-Vinson syndrome). In addition, many people report chronic itching.

Symptoms of vitamin B12 deficiency
If there is a deficiency of vitamin B12, in addition to general symptoms of anemia, neurological symptoms may occur: Gait unsteadiness, paralysis, painful tingling and numbness in the hands and feet. In the case of unclear neurological symptoms, the possibility of a vitamin B12 deficiency should therefore always be considered.

Supplementary pernicious anemia (pernicious anemia, Biermer's disease). It is also caused by a vitamin B12 deficiency – but it is based on an autoimmune disease. The disease leads to the destruction of certain stomach cells, the parietal cells. These normally produce a protein responsible for binding and absorbing vitamin B12: intrinsic factor. If it is absent, the body cannot absorb vitamin B 12. The cause of the disease is atrophic gastritis (inflammation of the gastric mucosa). Typical symptoms of pernicious anemia are, in addition to the above-mentioned complaints, mucosal changes of the tongue (Hunter's glossitis) with a smooth red tongue and burning of the tongue. However, this form of anemia is very rare. Sometimes pernicious anemia occurs concomitantly with hypothyroidism. Possibly physical symptoms such as dizziness. fatigue the patient to the doctor. Anemia can also occur as a side effect of other diseases or as a side effect of medications. It is therefore important to inform the doctor in detail about any medications taken regularly and about any existing complaints. After such points have been clarified in a conversation, a physical examination usually follows.

First indications of anemia may be an unusual pallor of the skin or mucous membranes, such as the conjunctiva of the eyes. An increased pulse or heart murmurs are other possible signs. Symptoms of iron deficiency (see paragraph Symptoms) may also lead the doctor to suggest a laboratory examination of the blood. In many cases, however, anemia is discovered by chance during an examination of the blood for other reasons.

The diagnosis "anemia is confirmed by a so-called blood count, which provides information about the number of red blood cells and the amount of red blood pigment, among other things. The next step is to determine the cause of the anemia. Certain indications of the origin of the disorder can already be found in the blood count. The doctor can then order the necessary further examinations.

Blood examination: The shape of the blood cells, for example, can be identified with the microscope

© Jupiter Images GmbH/Comstock Images

Examination of the blood in the laboratory

In order to diagnose anemia, the family doctor will take a blood sample and order a small blood count from the laboratory. This will include the following values, which may indicate not only anemia, but already its origin:

Number of red blood cellsIf there are too few erythrocytes, this indicates anemia. Amount of red blood pigment (hemoglobin value, Hb): This is an important parameter for the diagnosis of anemia. This is because the red blood pigment plays the decisive role in the transport of oxygen. If it is decreased, it means that anemia is present Hematocrit (Hct): It quantifies the proportion of the solid components of the blood, i.e. the cells, in the total blood volume. Since most cells in the blood are red blood cells, the hematocrit also indirectly provides information about the amount of erythrocytes. However, the hematocrit is also decisively influenced by changes in the fluid balance. A reduced hematocrit can therefore indicate anemia, but there may also be other causes behind it. Mean erythrocyte hemoglobin (MCH): MCH is a value that indicates how much red blood pigment is contained in an erythrocyte on average. If the value is low, this indicates that a disorder in the formation of the red blood pigment is responsible for the anemia. If the MCH is normal, it is called normochromic anemia. If it is reduced, we speak of hypochromic anemia, i.e. anemia with reduced hemoglobin content of the erythrocytes. If the MCH is elevated, the cause is hyperchromic anemia, anemia with increased hemoglobin content of the erythrocytes. Mean erythrocyte volume (MCV): The MCV quantifies the average size or the volume of the individual red blood cells. If the MCV is normal, we speak of normocytic anemia; if it is reduced, we speak of microcytic anemia, i.e. anemia with cells that are too small. If the MCV is increased, it is a macrocytic anemia, an anemia with enlarged cells. White blood cells (leukocytes), Platelets (Platelets): The number of white blood cells and platelets is also determined as part of a small blood count. These values are important for the assessment of anemia. In the case of infections or some chronic diseases, for example, there is an increase in leukocytes; in the case of bleeding, the platelets are often also increased as part of the recovery of the blood values; in the case of diseases of the bone marrow, not only the red blood cells but also the other cell types are often altered in their numbers, so that these findings can be indicative for further clarification.

Clarification of the cause

If the laboratory findings indicate that anemia is present, the next step is to clarify the cause. First indications can already be MCH. provide MCV (see paragraph "Examination of blood in the laboratory"). If the red blood cells are reduced in size (MCV low) and show a decreased mean erythrocyte hemoglobin concentration (MCH), this may indicate an iron deficiency, for example. However, other diseases such as thalassemia (genetic defect of hemoglobin) are also possible.

If the erythrocytes are enlarged (MCV high) and the mean erythrocyte hemoglobin concentration (MCH) is elevated, a vitamin B12 or folic acid deficiency, for example, or certain bone marrow diseases may be the cause.

For further clarification, a differential blood count (large blood count) is necessary, in which the cells are looked at under the microscope. In the case of diseases with typical forms of red blood cells, such as spherocytosis or thalassemia, this test provides the decisive diagnostic clues.

The number of reticulocytes is determined in order to clarify whether it is a production disorder or an increased degradation of the red blood cells. These are immature precursors of erythrocytes in the blood. To correct a deficiency of erythrocytes in the blood, the body first releases red blood cells from its reserves in the bone marrow. If there are not enough mature erythrocytes available, the not quite mature precursors, the reticulocytes, are also released into the blood.

A high number of reticulocytes in the blood indicates that many red blood cells are being lost and the body is trying to replenish them quickly. The main causes are bleeding or increased breakdown or decay of the blood cells.

On the other hand, a low number of reticulocytes in the blood in the presence of anemia indicates that not enough red blood cells can be produced. This may be caused, for example, by a disease of the bone marrow. Another possibility is a deficiency of erythropoietin (EPO). The hormone is normally produced in the kidneys. Promotes the production of red blood cells in the bone marrow.

Further examinations if a formation disorder is suspected

Clarification of a possible iron deficiency and its cause: Iron deficiency anemia can be clarified with the help of further laboratory tests. In addition, the doctor will determine a protein that is responsible for binding iron: ferritin. Ferritin circulating in the blood correlates well with the body's iron stores. Bleeding is a common cause of iron deficiency. Therefore, the physician will also order tests to rule out such a cause. If there is no evidence of bleeding, the reason for the iron deficiency is most likely to be found in the diet. Vegetarians, for example, sometimes consume too little of the trace element.

Only in rare cases is iron deficiency due to a disorder in the digestive system – not enough of the mineral is absorbed in the upper small intestine. Another cause of iron deficiency anemia may be infection or parasite infestation. If it is suspected, the doctor will order appropriate stool tests.

Clarification of a folic acid and/or vitamin B12 deficiency and its cause: A folic acid or vitamin B12 deficiency can also be determined on the basis of certain blood values. The level of folic acid in the blood can be determined in the laboratory. If the value is too low, this is usually due to malnutrition or a resorption disorder. Then the folic acid level must be normalized by a change in the diet and the additional administration of the vitamin. The amount of vitamin B12 in the blood can also be determined in the laboratory. If the vitamin B12 level is too low, the doctor will then seek further diagnostics.

Clarification of kidney-related anemia: First, an examination of certain blood values is used to clarify whether there could be damage to the kidney. If there are indications of kidney dysfunction, the level of the neurotransmitter erythropoietin in the blood is measured. If this value is lowered, it means that the signal to the bone marrow, which is necessary for the formation of red blood cells, is missing. However, it is first necessary to exclude a possible iron deficiency.

Clarification of a stem cell disease or a bone marrow infection: If a disorder of hematopoiesis is suspected without a deficiency of iron, vitamin B12, folic acid or erythropoietin being detected, a disease of the stem cells or bone marrow must be considered. In such cases, a bone marrow puncture is usually performed. In this examination, bone marrow is removed from the pelvic bone with a needle under local anesthesia, processed, stained and examined under the microscope.

Test for blood in the stool: If blood cells are lost via the intestine?

Further testing if increased red cell breakdown or loss is suspected:

Clarification of a possible bleedingDepending on which cause seems most likely to the physician, he will initiate further examinations. If the aim is to exclude bleeding or to find the source of bleeding, he will order a test for blood in the urine and blood in the stool. Women are also asked about their menstrual periods. If necessary, also recommend a gynecological examination. If the results of these tests are abnormal, further examinations (e.g. gastroscopy, colonoscopy, capsule endoscopy) may be necessary. Clarification of a possible spleen enlargementIf the spleen is significantly enlarged, this can usually be detected during the physical examination. If the spleen is moderately enlarged, an ultrasound examination may be needed for detection. Clarification of possible hemolysisIn addition to the above-mentioned detailed blood test and reticulocyte count, there are other laboratory values that can indicate increased blood loss. These so-called hemolysis parameters are lactate dehydrogenase (LDH) and indirect bilirubin. Both are elevated in the case of a hemorrhage. The value of haptoglobin, on the other hand, is lowered. If the suspicion of hemolytic anemia is confirmed, further clarification is recommended. Further examinations To clarify other causes: Other causes of anemia can sometimes be detected by special molecular biology tests. In case of hereditary diseases, special genetic tests are also used.

Anemia apotheken umschau

In case of severe blood loss, a transfusion may be necessary

Therapy options

How the doctor treats the anemia depends on the underlying cause. For some common forms of anemia, therapy is briefly outlined below.

In case of anemia caused by blood loss, the source of bleeding should be eliminated or stopped as soon as possible. Acute bleeding, for example after accidents, must be treated immediately. In cases of particularly extensive blood loss, a blood transfusion from donated blood may be vital.

If an iron deficiency is due to an insufficient intake of the trace element in the diet, the person affected should, if possible, change his or her diet so that sufficient iron is absorbed. Meat, fish, poultry and nuts are rich in iron. Smaller amounts of iron are also found in milk, eggs, legumes and cereals. The iron contained in meat is in a form that we can process particularly well. Vegetable iron, on the other hand, can be utilized less effectively.

If a change in diet is not sufficient, iron in the form of tablets can help. Iron supplements should be taken daily or every other day on an empty stomach, as prescribed by the doctor. After three to six months, the body's iron stores are usually replenished. Among the most frequently described side effects are mainly gastrointestinal complaints. Stomach-sensitive people take iron supplements best during or after a meal – even though it is then absorbed less easily by the body than on an empty stomach. Sometimes changing the iron supplement can also help. Iron supplements are tolerated to varying degrees. They can also turn the stool black. When dissolved in the mouth, lead to blackening of the tongue. Iron should not be taken at the same time as certain antibiotics or medicines to neutralize stomach acid (antacids). About possible interactions inform doctor or pharmacist.

If the cause of iron deficiency anemia is a disturbance in the absorption of the trace element in the intestine, as in inflammatory gastrointestinal diseases, or if severe side effects occur during therapy with iron tablets, iron therapy via the vein is an option.

In the diet, folic acid is mainly present in green vegetables or whole grain products. Folic acid can also be taken in tablet form. Avoid malnutrition, which often occurs as a result of an unbalanced diet or alcohol abuse. Some drugs can also cause a folic acid deficiency – for example methotrexate, which is used to treat rheumatoid arthritis.

The body only needs very small amounts of vitamin B12. Therefore, it rarely happens that the diet does not cover the requirement. Only in very strict vegetarians or vegans does it occasionally occur. However, vitamin B12 deficiency can also occur after extensive operations – for example stomach surgery – or in parasitic diseases (infestation by the fish tapeworm).

In these cases, the diet must be changed or vitamin B12 must be administered as prescribed by the doctor – preferably by injection. If the vitamin B12 deficiency is due to reduced absorption of the vitamin in the intestine, high-dose oral preparations can also help. On the other hand, there is little benefit from taking vitamin B12 with food or in the usual tablet form.

Treatment options for other forms of anemia

Also for the other kinds of anemia there is often an efficient treatment, which depends on the respective cause. For example, the doctor can use the hormone erythropoietin in kidney disease with accompanying renal anemia. It stimulates the blood formation.

There are also special therapies for the various stem cell diseases such as aplastic anemia or paroxysmal nocturnal hemoglobinuria. Special therapies are also available for diseases with increased cell decay. If the anemia is caused by another underlying disease, this should be treated first.

Generally speaking: The causes of anemia are many. A therapy should in no case be carried out on one's own without clarification. Recommendation of the caring physician to be made. Because a treatment that is very helpful in one form of anemia – such as iron administration – can even be harmful in the long run in another type of anemia.

Consulting expert

Dr. med. Ferras Alashkar works as an assistant physician in the Clinic for Hematology at the University Hospital in Essen, Germany. He graduated from the Iuliu Hațieganu Medical and Pharmaceutical University in Cluj-Napoca, Romania, and from the University of Duisburg-Essen, Germany. The clinical training subsequently took place at the Justus Liebig University in Giessen in the field of internal oncology and palliative medicine. Since 2012, he has been working in the Department of Hematology at the University Hospital of Essen, Germany. As part of his work, he is involved in numerous studies and, in addition to the inpatient as well as outpatient care of patients, is involved scientifically, especially in the field of anemias, such as aplastic anemia and paroxysmal nocturnal hemoglobinuria (PNH). This article contains only general information. Should not be used for self-diagnosis or self-treatment. It cannot replace a visit to the doctor. Unfortunately, it is not possible for our experts to answer individual questions.

Like this post? Please share to your friends:
Leave a Reply

;-) :| :x :twisted: :smile: :shock: :sad: :roll: :razz: :oops: :o :mrgreen: :lol: :idea: :grin: :evil: :cry: :cool: :arrow: :???: :?: :!: