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Allergic reactions are more common following concentrates in preference to gastritis pills 10 mg motilium sale cryoprecipitate infusion of cryoprecipitate than concentrate [21] gastritis help purchase motilium 10 mg online. Due to stomach ulcer gastritis symptoms generic 10 mg motilium with mastercard concerns about the safety and quality of cryoprecipitate gastritis diet best motilium 10 mg, its use in the treatment of 2. Although the manufacture of small pool, viralinactivated cryoprecipitate has been described, it Cryoprecipitate is uncertain whether it ofers any advantage with respect to overall viral safety or cost beneft over 1. Each patients response should be tested prior to concentrates, other agents can be of great value therapeutic use, as there are signifcant diferin a signifcant proportion of cases. The response to desmopressin intranasal desmopressin is more variable and tranexamic acid therefore less predictable. It is dicated in children under two years of age who important to choose the correct preparation of are at particular risk of seizures secondary to desmopressin because some lower-dose preparacerebral edema due to water retention. Tranexamic acid is an antifbrinolytic agent that competitively inhibits the activation of plasmin4. The peak response is seen approximately 60 minutes afer administration either intravenously 3. For an individual with a bodyweight of less than Dosage/administration 40 kg, a single dose in one nostril is sufcient. Tough the intranasal preparation is available, intravenous infusion two to three times daily, some patients fnd it difcult to use and it may be and is also available as a mouthwash. If treatment with both agents is deemed necesrhea) may rarely occur as a side efect, but these sary, it is recommended that at least 12 hours symptoms usually resolve if the dosage is reduced. If this is not available, a tablet can be crushed and dissolved in clean water for topical Epsilon aminocaproic acid use on bleeding mucosal lesions. Tranexamic acid is commonly prescribed for tranexamic acid but is less widely used as it has seven days following dental extractions to prevent a shorter plasma half-life, is less potent, and is post-operative bleeding. Tranexamic acid is excreted by the kidneys and the dose must be reduced if there is renal impairDosage/administration ment in order to avoid toxic accumulation. The use of tranexamic acid is contraindicated for or intravenously every four to six hours up to a the treatment of hematuria as its use may prevent maximum of 24 g/day in an adult. Similarly, the drug is contraindicated in the setting of thoracic surgery, where it may result 4. Myopathy is a rare adverse reaction specifcally in the development of insoluble hematomas. Tranexamic acid may be given alone or together occurring afer administration of high doses for with standard doses of coagulation factor several weeks. Guideline for the use of fresh frozen plasma, trials in hemophilia B and comparison to prothrombin cryoprecipitate and cryosupernatant. Semin cryoprecipitate for abnormalities of coagulation tests Tromb Hemost 2008;34(8):747-61. Protocols for the treatment of Ben-Hur E, Hamman J, Jin R, Dubovi E, Horowitz hemophilia and von willebrand disease. Surgery for hemophilia procedures in adult patients with hereditary bleeding in developing countries. Semin Tromb Hemost 2005 disorders: 10 years experience in three Italian Nov;31(5):538-43. Intranasal laboratory haemostasis: a prospective crossover study of desmopressin (Octim): a safe and efcacious intranasal desmopressin and oral tranexamic acid. Desmopressin: safety Tranexamic acid combined with recombinant considerations in patients with chronic renal disease. The use of topical crushed tranexamic acid tablets to control bleeding afer dental surgery and from skin ulcers in haemophilia. Bleeding in patients with hemophilia can occur at and corrected while other measures are being diferent sites (see Table 1-2 and Table 1-3), each planned. As a general principle in case of large internal hemorrhage, hemoglobin should be checked 5. A target joint is a joint in which 3 or more spontaized by rapid loss of range of motion as compared neous bleeds have occurred within a consecutive with baseline that is associated with any combina6-month period. Following a joint bleed, fexion is usually the most in the joint, palpable swelling, and warmth of the comfortable position, and any attempt to change skin over the joint [1]. Secondary muscle spasm follows as the patient tries described by patients as a tingling sensation and to prevent motion and the joint appears frozen. The goal of treatment of acute hemarthrosis is to stop the bleeding as soon as possible. The earliest clinical signs of a joint bleed are ideally occur as soon as the patient recognizes increased warmth over the area and discomfort the aura, rather than afer the onset of overt with movement, particularly at the ends of range. Administer the appropriate dose of factor tion either on treatment or within 72 hours afer concentrate to raise the patients factor level stopping treatment [1]. Rehabilitation must be stressed as an active mended for the assessment of response to part of the management of acute joint bleeding treatment of an acute hemarthrosis [1]. Instruct the patient to avoid weight-bearing, subside, the patient should be encouraged to apply compression, and elevate the afected change the position of the afected joint from joint. Consider immobilizing the joint with a splint gradually decreasing the fexion of the joint until pain resolves. Gentle passive for 15-20 minutes every four to six hours for assistance may be used initially and with pain relief, if found benefcial. If bleeding does not stop, a second infusion aged to minimize muscle atrophy and prevent may be required. Further evaluation is necessary if the patients restored and signs of acute synovitis have dissisymptoms continue longer than three days. Signifcant pain relief and/or improvement in signs of bleeding within approximately 8 hours after a single Good injection, but requiring more than one dose of replacement therapy within 72 hours for complete resolution. Modest pain relief and/or improvement in signs of bleeding within approximately 8 hours after the initial Moderate injection and requiring more than one injection within 72 hours but without complete resolution. None No or minimal improvement, or condition worsens, within approximately 8 hours after the initial injection. Note: the above defnitions of response to treatment of an acute hemarthrosis relate to inhibitor negative individuals with hemophilia. These defnitions may require modifcation for inhibitor positive patients receiving bypassing agents as hemostatic cover or patients who receive factor concentrates with extended half-lives. Arthrocentesis unusual increase in local or systemic temperature and other evidence of infection (septic 1. Arthrocentesis (removal of blood from a joint) arthritis) (Level 3) [4,9,10] may be considered in the following situations: a bleeding, tense, and painful joint which 2. Inhibitors should be considered as a reason shows no improvement 24 hours afer conserfor persistent bleeding despite adequate factor vative treatment replacement. The presence of inhibitors must joint pain that cannot be alleviated be ruled out before arthrocentesis is attempted. The early removal of blood should theoretically should be used for the procedure, as needed. Weight-bearing should be avoided for 2448 performed under factor levels of at least 3050 hours. Symptoms of muscle bleeds are: body, usually from a direct blow or a sudden aching in the muscle stretch. A muscle bleed is defined as an episode of severe pain if the muscle is stretched bleeding into a muscle, determined clinically pain if the muscle is made to actively contract and/or by imaging studies, generally associated tension and tenderness upon palpation and with pain and/or swelling and functional impairpossible swelling ment. Early identifcation and proper management of possible, ideally when the patient recognizes muscle bleeds are important to prevent permathe frst signs of discomfort or afer trauma. Sites of muscle bleeding that are associated with as symptoms indicate (refer to Tables 7-1 and neurovascular compromise, such as the deep 7-2). Splint the muscle in a position of comfort and the iliopsoas muscle (risk of femorocutaneous, adjust to a position of function as pain allows. Ice/cold packs may be applied around the muscle the superior-posterior and deep posterior for 15-20 minutes every four to six hours for compartments of the lower leg (risk of postepain relief if found benefcial. Do not apply ice rior tibial and deep peroneal nerve injury) in direct contact with skin. Repeat infusions are ofen required for two to three days or much longer in case of bleeds at 5. Bleeding can also occur in more superficial critical sites causing compartment syndromes muscles such as the biceps brachii, hamstrings and if extensive rehabilitation is required. The patient should be monitored continuously the thigh or other signs of femoral nerve compresfor neurovascular compromise; fasciotomy may sion such as loss of patellar refex and quadriceps be required in some such cases.

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Sexual assault forensic medical examination: is evidence related to gastritis y reflujo discount motilium successful prosecutionfi Dardamissis E gastritis symptoms lower back pain discount motilium 10 mg fast delivery, Gee A gastritis symptoms bad breath buy motilium 10 mg low price, Kaczmarski E gastritis or pancreatic cancer order discount motilium, et al on behalf of the North West Policy Group. Guidance for healthcare professionals on dealing with injuries where teeth break the skin. A national protocol for sexual assault medical forensic examinations adults/adolescents. Urethrography and cavernosography imaging in a small series of penile fractures: a comparison with surgical findings. Trauma to male genital organs: a 10-year review of 156 patients, including 118 treated by surgery. The value of magnetic resonance imaging in the diagnosis of suspected penile fracture with atypical clinical findings. Magnetic resonance imaging and ultrasound evaluation of penile and testicular masses. Value of testicular ultrasound in the evaluation of blunt scrotal trauma without haematocele. Boston Bombings: a surgical view of lessons learnt from combat Casualty care and the applicability to Bostons terrorist attack. Recent progress in surgery for the victims of disaster, terrorism, and war-Introduction. Traumatic ureteral injuries: a single institution experience validating the American Association for the Surgery of Trauma-Organ Injury Scale grading scale. Planned reoperation for trauma: a two year experience with 124 consecutive patients. Medical management of disasters and mass casualties from terrorist bombings: how can we copefi This information is publically accessible through the European Association of Urology website. From both literature and daily practice it has become clear that abdominal and pelvic pain are areas still under development. This guideline has been recognised as a cornerstone for important developments that have taken place in the past 10 years. This guideline aims to expand the awareness of caregivers in the field of abdominal and pelvic pain, and to assist those who treat patients with abdominal and pelvic pain in their daily practice. The guideline is a useful instrument not only for urologists, but also for gynaecologists, surgeons, physiotherapists, psychologists and pain doctors. We therefore plan to make a stepped information structure, in alignment with stepped care protocols. It is the vision of the panel to use new digital information sources like websites and apps to aid this process. It has been recognised that structuring a guideline on chronic pain is quite different from structuring one on another subject. For the 2016 version the panel has made plans focussing on two important changes to the guideline. The first one is to rewrite the guideline in such a way that it is centred around pain instead of being organ centred. Chapters are now named after the organ or after the specialist that is consulted by the patient. For the 2016 edition of this guideline, pain will be the centre and every other information will be build around this central theme. The guideline will be partly theoretical to elucidate the importance of using a pain centred approach. The biggest part however, will deal with the practical approach in diagnostics, treatment and management of patients with abdominal and pelvic pain. The second change the panel is working on is the way of presenting those practical aspects of pain. The guideline will, based on pain in the centre, lead the healthcare professional through the different steps in the process of dealing with abdominal and pelvic pain patients. This second focus of updating will be of great importance for developing modern ways to make information available for the general practitioner who sees the patient in their office. It will contain red flags, associated conditions and available first line treatments. It should also be available for the medical specialist who gets a patient with chronic pain referred. The guideline will highlight necessary investigations and phenotyping, treatment options, decision making on whether a treatment is rational or not, and how and when to refer to a specialised pelvic pain centre. Caregivers who treat patients for pain related problems like myofascial and sexological dysfunctions will find help in making treatment plans and in the timing of referring back to specialised care. The guideline will also aid those involved in coaching self management and shared care. Two chapters were added at that time: Chapter 5 Gastrointestinal aspects of chronic pelvic pain and Chapter 7 Sexological aspects of chronic pelvic pain. In the 2014 edition minor revisions were made in the Chapters 5 Gastrointestinal aspects of chronic pelvic pain and 8 Psychological aspects of chronic pelvic pain. We did a major reduction especially in Chapter 3 Urological aspects of chronic pelvic pain. The subchapter on bladder pain syndrome was very critically revised and is now a comprehensive part of the guidelines. The fact that this part was so extensive shows that the roots of talking about abdominal and pelvic pain lies in the bladder, where Interstitial Cystitis was one of the first subjects addressed talking about pain in urology. The Panel has illustrated this in the publication in European Urology in 2013 [5]. Alongside the full text version, a quick reference document (Pocket Guidelines) is available, presenting key findings of the Chronic Pelvic Pain Guidelines. These reference documents follow the updating cycle of the underlying large texts. Extensive use of free text ensured the sensitivity of the searches, resulting in a substantial body of literature to scan. Searches covered the period January 1995 and July 2011 and were restricted to English language publications. Further updates of Chapter 5 Gastrointestinal aspects of chronic pelvic pain and Chapter 8 Psychological aspects of chronic pelvic pain in the 2014 edition were based on systematic reviews of the literature in the aforementioned databases including PsycInfo. As well as pain, these central mechanisms are associated with several other sensory, functional, behavioural and psychological phenomena. It is this collection of phenomena that forms the basis of the pain syndrome diagnosis and individual phenomena need to be addressed in their own right through multispecialty and multidisciplinary care. The main exception is when pain is due to peripheral nerve damage, which will be discussed in Chapter 6. Ongoing acute pain mechanisms [6] (such as those associated with inflammation or infection), which may involve somatic or visceral tissue. Table 1 illustrates some of the differences between the somatic and visceral pain mechanisms. They underlie some of the mechanisms that may produce the classical features of visceral pain; in particular, referred pain and hyperalgesia. Table 1: Comparison between visceral and somatic pain Visceral pain Somatic pain Effective painful stimuli Stretching and distension, Mechanical, thermal, chemical and producing poorly localised pain. Summation Widespread stimulation produces Widespread stimulation produces a significantly magnified pain. Referred pain Pain perceived at a site distant to Pain is relatively well localised but the cause of the pain is common. Referred hyperalgesia Referred cutaneous and muscle Hyperalgesia tends to be localised. Innervation Low density, unmyelinated C fibres Dense innervation with a wide and thinly myelinated Afi fibres. Separate fibres increases, afferent firing increases for pain and normal sensation. Silent afferents 50-90% of visceral afferents Silent afferents present, but form a are silent until the time they are lower percentage. Sensations not normally perceived become perceived and non-noxious sensations become painful.

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He has a family history of haemophilia and has been diagnosed with mild haemophilia A gastritis symptoms causes and treatment generic motilium 10mg amex. The risk-benefit ratio of regional anaesthesia must be assessed on a case-by-case basis after correction of deficient factor levels gastritis clear liquid diet motilium 10 mg generic. However gastritis diet purchase 10mg motilium with amex, naproxen can cause platelet dysfunction and aggravate postoperative bleeding; it should be avoided gastritis diet ayurveda generic motilium 10 mg without prescription. Deficient factor levels must be monitored both preoperatively and postoperatively. They must be maintained within normal range (50-150%) during the perioperative period and for 4 to 6 weeks after major orthopaedic and joint replacement surgery. On the day of surgery you note an irregular pulse rate of 105 beats per minute and a blood pressure of 165/95 mmHg. Appropriate statements regarding immediate management include: a) Check serum electrolytes; if they are normal, then proceed with induction of general anaesthesia. Anaesthesia and surgery may precipitate fast atrial fibrillation in the absence of electrolyte abnormalities. A hypertensive patient with atrial fibrillation may have structural heart disease that will not tolerate tachyarrhythmias. Out-patient rate control, blood pressure control, an echocardiogram and exercise tolerance test are warranted prior to elective surgery for this patient. However, for this patient further investigations and an opinion from a cardiologist are required. In the elective setting, it is most appropriate to investigate and pre-optimise a patient prior to anaesthesia and surgery. Two days ago she had a laparoscopically assisted hysterectomy under general anaesthesia. An Ear Nose and Throat surgeon is on the ward reviewing her and together you perform a nasendoscopy. Appropriate statements regarding this scenario include: a) the patients right vocal cord is in an abnormal position. Left recurrent laryngeal nerve injury results in the left vocal cord being in the paramedian position. There is unopposed action of the cricothyroid muscle which adducts and tenses the vocal cord. The cricothyroid is innervated by the superior laryngeal nerve but not the recurrent laryngeal nerve c) True. The smaller female glottis appears to be more vulnerable to injury from tracheal intubation. The recurrent laryngeal nerve (which innervates the intrinsic muscles of the larynx except cricothyroid) is vulnerable to compression from a tracheal cuff positioned just below the vocal cords. The pain started after what she describes as a water infection and persists despite numerous courses of antibiotics. At cystoscopy by an urologist, the only abnormality was the presence of granulations in the bladder mucosa. Over the course of her illness, her symptoms have become progressively worse, especially in the days leading up to her period. She experiences difficulty initiating micturition, symptoms of urge with occasional incontinence, pain on sexual intercourse and persistent constipation. Of note in the past, she has had a sterilisation procedure after the birth of her second child. There are tender points in the lumbar paraspinal area, anterior abdominal wall and pelvic floor muscles. Voluntary contraction of the pelvic floor and vaginal examination are associated with reproduction of pain. As the pain is not relieved by paracetamol, naproxen and codeine, she finds it difficult to cope and fears for the future. Appropriate statements regarding this situation include: a) the diagnosis is likely to be Bladder Pain Syndrome or Interstitial Cystitis b) the combination of urge with incontinence together with difficulty initiating micturition make an underlying psychiatric diagnosis likely c) the absence of neurological features mean it is unlikely she will respond to anti-neuropathic medication d) Strong opioid analgesia such as morphine would be a good option in the first instance e) Medication often used for hormonal contraception is unlikely to be of benefit as she has already been sterilised. Although there were organ-specific features at the start of her illness, there is now evidence of dysfunction in other areas such as sex and bowel function. There is also a cyclical component and a suggestion of negative psychological consequences associated with the pain. Dysfunction can be due to underactive pelvic floor (for example stress incontinence), overactive pelvic floor (pain and Examples of multiple choice questions. Additionally, functional bladder problems such as detrusor instability may complicate the clinical picture. Mixed or unusual presentations are often ascribed to psychological or psychiatric causes although there is no evidence to support this conclusion. Drugs with anticholinergic side effects such as amitriptyiline and duloxetine may be useful when the patient has urinary frequency and urge. However, the potential benefits have to be balanced against the risk of exacerbating constipation. Patients with cyclical pain should be considered for hormonal contraception therapy. Sterilisation does not imply that the patient is not responsive to hormomal therapy. He has collapsed during exercise and is diagnosed with hypovolaemia and rhabdomyolysis secondary to extreme 1 1 exercise. Appropriate statements regarding myoglobin and the diagnosis of rhabdomyolysis include: a) Urinary dipstick for blood is likely to detect myoglobin in the absence of trauma to the urinary tract. Urinary dipstick for blood is positive in the presence of myoglobin and has a sensitivity of 81% for the detection of rhabdomyolysis. Rhabdomyolysis is typically diagnosed when the creatine kinase is >5000 u litre c) False. Myoglobin is rapidly metabolized, so myoglobinuria may not be present at the time of testing in the presence of rhabdomyolysis. However, since myoglobin is rapidly metabolized outside the kidney (probably through the liver or spleen), creatine kinase a more reliable marker than myoglobin. A creatine kinase greater than five times the upper limit of normal is the usual standard 1 (>5000 u litre). Statements referring to appropriate patient consent for this process include: a) the patient considers the risks of this process but agrees voluntarily for training to proceed. Hetereonomy means that the will of an individual is governed by an outside force or power. Patients have the right to rescind their consent if they wish; this must be made clear to them. Bilateral percutaneous cervical cordotomies may be performed, but they are associated with a high incidence of respiratory failure. As with all neurodestructive interventions, there is a risk of delayed onset neuropathic pain. Percutaneous cervical cordotomy is neither used for nonmalignant pain nor in cancer patients with long life expectancy. It does not relieve pain originating above the level of the 2nd cervical dermatome since it is performed at this level. During unilateral percutaneous cervical cordotomy, there is block of transmission of pain (and temperature) in ascending fibres that have crossed from the side of the pain to the side of the nd block, caudal to the 2 cervical dermatome. Percutaneous cervical cordotomy may be offered when failure of less invasive techniques is anticipated. Percutaneous cervical cordotomy is not a rescue procedure; the patient must be able to travel to the treatment centre and lie flat and still for 40 to 90 minutes. Immediately prior to the transfusion, his haemoglobin concentration was 83 g l 1 1 (normal range 138-172 g l). Within 15 minutes of the start of the infusion he complains of pain at the infusion site, nausea and back pain. They reveal the following results: 1 1 haemoglobin concentration of 71 g l (normal range is 138 to 172 g l), prothrombin time of 17.

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The term band cell should be used when all nuclear sections of the nucleus are approximately the same width (the bands) gastritis diet menus order cheapest motilium. The beginnings of segmentation may be visible gastritis spanish cheap motilium 10mg with amex, but the indentations should never cut more than two-thirds of the way across the nucleus gastritis je discount motilium 10 mg on line. Segmented neutrophils represent the final stage in the lineage that started with myeloblasts gastritis upper gi cheap motilium american express, forming gradually, without any clear transition or further cell divisions, by increasing contraction of their nuclei. Finally, the nuclear segments are connected only by narrow chromatin bridges, which should be no thicker than one-third of the average diameter of the nucleus. The chromatin in each segment forms coarse bands, or patches and is denser than the chromatin in band neutrophils. The cytoplasm of segmented neutrophilic granulocytes varies after staining from nearly colorless to soft pink or violet. The following approximate values are taken to represent a normal distribution: 1030% have two segments, 4050% have three segments, 1020% have four segments, and 05% of the nuclei have five segments. A left shift to smaller numbers of segments is a discreet symptom of reactive activation of this cell series. A right shift to higher numbers of segments (oversegmentation) usually accompanies vitamin B12 and folic acid deficiencies. Banded neutrophilic granulocytes (band neutrophils) may occur in small numbers (up to 2%) in a normal blood count. A higher proportion than 2% may indicate a left shift and constitute the first sign of a reactive condition (p. The diagnostic value of segmented neutrophilic granulocytes (segmented neutrophils) is that normal values are the most sensitive diagnostic indicator of normally functioning hematopoiesis (and, especially, of normal cellular defense against bacteria). An increase in segmented neutrophils without a qualitative left shift is not evidence of an alteration in bone marrow function, because under certain conditions stored cells may be released into the peripheral blood (for causes, see p. In conjunction with qualitative changes (left shift, toxic granulations), however, granulocytosis does in fact indicate bone marrow activation that may have a variety of triggers (pp. Advancing nuclear contraction and segmentation: continuous transformation from metamyelocyte to band cell and then segmented neutrophilic granulocyte a b c d f e g Fig. This phenomenon is a consequence of activity against bacteria or proteins and is observed in serious infections, toxic or drug effects, or autoimmune processes. At the same time, cytoplasmic vacuoles are often found, representing the end stage of phagocytosis (especially in cases of sepsis), as are Dohle bodies: small round bodies of basophilic cytoplasm that have been described particularly in scarlet fever, but may be present in all serious infections and toxic conditions. A deficiency or complete absence of granulation in neutrophils is a sign of severe disturbance of the maturation process. The Pelger anomaly, named after its first describer, is a hereditary segmentation anomaly of granulocytes that results in round, rod-shaped, or bisegmented nuclei. The same appearance as a nonhereditary condition (pseudo-Pelger formation, also called PelEbstein fever, or [cyclic] Murchison syndrome) indicates a severe infectious or toxic stress response or incipient myelodysplasia; it also may accompany manifest leukemia. Note the granulations, inclusions, and appendages in segmented neutrophilic granulocytes a b c d Fig. Of these, only the drumstick form corresponds to the X-chromosome, which has become sequestered during the process of segmentation. A proportion of 15% circulating granulocytes with drumsticks (at least 6 out of 500) suggests female gender; however, because the drumstick form is easy to confuse with the other (insignificant) forms of nuclear appendage, care should be taken before jumping to conclusions. Rarely, degrading forms of granulocytes, shortly before cytolysis or apoptosis, may be found in the blood (they are more frequent in exudates). In these, the segments of the nucleus are clearly losing connection, and the chromatin structure of the individual segments, which are becoming round, becomes dense and homogeneous. Pseudo-Pelger granulocytes are observed in cases of infectioustoxic stress conditions, myelodysplasia, and leukemia. The use of nuclear appendages to determine gender has lost significance in favor of genetic testing. Note the granulations, inclusions, and appendages in segmented neutrophilic granulocytes e f g h Fig. The earliest point at which eosinophils can be morphologically defined in the bone marrow is at the promyelocyte stage. Promyelocytes contain large granules that stain bluered; not until they reach the metamyelocyte stage do these become a dense population of increasingly round, golden-red granules filling the cytoplasm. The CharcotLeyden crystals found between groups of eosinophils in exudates and secretions have the same chemical composition as the eosinophil granules. Basophilic Granulocytes (Basophils) Like eosinophils, basophils (basophilic granulocytes) mature in parallel with cells of the neutrophil lineage. The earliest stage at which they can be identified is the promyelocyte stage, at which large, blackviolet stained granules are visible. In mature basophils, which are relatively small, these granules often overlie the two compact nuclear segments like blackberries. However, they easily dissolve in water, leaving behind faintly pink stained vacuoles. Close relations of basophilic granulocytes are tissue basophils or tissue mast cellsbut these are never found in blood. Basophils are also increased in chronic myeloproliferative bone marrow diseases, especially chronic myeloid leukemia (pp. Round granules filling the cytoplasm: eosinophilic and basophilic granulocytes a b c d e f Fig. The granules are corpuscular like those of the eosinophilic granulocyte but stain deep blue to violet. Owing to their great motility and adhesiveness, mature monocytes are morphologically probably the most diversified of all cells. Measuring anywhere between 20 and 40 m in size, their constant characteristic is an ovoid nucleus, usually irregular in outline, with invaginations and often pseudopodia-like cytoplasmic processes. The fine, busy structure of their nuclear chromatin allows them to be distinguished from myelocytes, whose chromatin has a patchy, streaky structure, and also from lymphocytes, which have dense, homogeneous nuclei. The basophilic cytoplasmic layer varies in width, stains a grayish color, and contains a scattered population of very fine reddish granules that are at the very limit of the eyes resolution. These characteristics vary greatly with the size of the monocyte, which in turn is dependent on the thickness of the smear. Where the smear is thin, especially at the feathered end, monocytes are abundant, relatively large and loosely structured, and their cytoplasm stains light grayblue (dove gray). In thick, dense parts of the smear, some monocytes look more like lymphocytes: only a certain nuclear indentation and the thundercloud grayblue staining of the cytoplasm may still mark them out. Phagocytosis of erythrocytes and white blood cells (hemophagocytosis) may occur in some virus infections and autoimmune diseases. Monocytes show the greatest morphological variation among blood cells a b c d e f g h Fig. The cells encountered in circulating blood are mostly small lymphocytes with oval or round nuclei 69m in diameter. Detailed analysis under the microscope, using the micrometer screw to view the chromatin in different planes, reveals not the patch-like or banded structure of myeloblast chromatin, or the busy structure of monocyte chromatin, but slate-like formations with homogeneous chromatin and intermittent narrow, lighter layers that resemble geological break lines. Only a few lymphocytes display the violet stained stippling of granules; about 5% of small lymphocytes and about 3% of large ones. An important point is that small lymphocyteswhich cannot be identified as Tor B-lymphocytes on the basis of morphologyare not functional end forms, but undergo transformation in response to specific immunological stimuli. The final stage of Blymphocyte maturation (in bone marrow and lymph nodes) is plasma cells, whose nuclei often show radial bars, and whose basophilic cytoplasm layer is always wide. Values between 1500 and 4000/l and about 35% reflect normal output of the lymphatic system. Elevated absolute lymphocyte counts, often along with cell transformation, are observed predominantly in viral infections (pp. Relative increases at the expense of other blood cell series may be a manifestation of toxic or aplastic processes (agranulocytosis, p. A spontaneous decrease in lymphocyte counts is normally seen only in very rare congenital diseases (agammaglobulinemia [Bruton disease], DiGeorge disease [chromosome 22q11 deletion syndrome]). Mature plasma cells are rarely found in blood (plasma cell leukemia is extremely rare). Plasma-cell-like (plasmacytoid) lymphocytes occur in viral infections or systemic diseases (see p.

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