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By: Bruce Alan Perler, M.B.A., M.D.

  • Vice Chair for Clinical Operations and Financial Affairs
  • Professor of Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002711/bruce-perler

Response from the presented studies it is difficult to symptoms zyrtec overdose cheap duphalac online visa draw firm rates were assessed by incontinence episodes and conclusions: as most series are small medications held before dialysis purchase duphalac 100 ml without prescription, not randomized urodynamic parameters symptoms torn meniscus cheap 100 ml duphalac mastercard. Detrusor overactivity completely resolved In a more recent uncontrolled study by Donohoe et in 35% 5 medications related to the lymphatic system generic duphalac 100 ml with visa. Four children had medication related adverse al a total of 26 patients with Primary Bladder Neck effects including headache, dizziness, abdominal Dysfunction (20 males, 6 females, mean age 12. Mean follow-up was 31 months and no major adverse Recently a randomized, double-blind, placeboside effects were observed. While the use of diapers, permanent catheters, external appliances and various forms of Level of evidence 3. Grade of recommendation B/C urinary diversion were acceptable treatment modalities; the limited number of identified randomized controlled these are now reserved for only a small number of trials does not allow a reliable assessment of the resistant patients [1]. Initially long term renal benefits and harms of different methods of manapreservation was the only aim of therapy and early gement in children. Further work is required in this diversion had the best long term results for preserving difficult clinical area. Despite some of the complications of measures is needed, to facilitate randomized controlled ileal conduits and cutaneous urostomies requiring trials of routine therapy. Interventions that would benefit secondary surgery, this form of treatment offered the from further investigations include: bladder and voiding best outcome for renal preservation with socially education, bladder retention training, bowel manaacceptable continence [2]. Only successful treatment option, but also made surgical then can the efficacy of new interventions be measured creation of continent reservoirs a very effective in children with detrusor overactivity or dysfunctional alternative with a good quality of life [3]. About 15 % of neonates rigorously evaluated in careful clinical trials with an with myelodysplasia have no signs of lower urinary appropriate study design. Development of less invasive evolved it allowed us to understand the nature and methods of diagnosis and treatment should therefore severity of the problems and administer management be encouraged. These children may present with accompanying deficiency contributes to a variable presentation of spinal cord pathology. This term includes a group of patients is important to improve the child’s chance of lesions like spina bifida occulta, meningocele, maintaining healthy kidneys and becoming continent. The purpose of any classification system is to facilitate the neurologic lesions produced by myelodysplasia the understanding and management of the underlying are variable contingent on the neural elements that pathology. Additionally, different growth rates between primarily to describe those types of dysfunction the vertebral bodies and the elongating spinal cord can secondary to neurologic disease or injury. Such introduce a dynamic factor to the lesion and scar tissue systems are based on the localization of the neurologic surrounding the cord at the site of meningocele closure lesion and findings of the neuro-urologic examination. These classifications have been of more value in In occult myelodysplasia the lesions are not overt and adults as neurogenic lesions are usually due to trauma often with no obvious signs of neurologic lesion. Yet, in nearly 90% of patients, a Indeed, severe detrusor sphincter dysfunction has cutaneous abnormality overlies the lower spine and been associated with minimal bony defects. Various this condition can easily be suspected by simple possible neuropathologic lesions of the spinal cord inspection of the lower back. These cutaneous lesions including syringomyelia, hydromyelia, tethering of the can vary from a dimple or a skin tag to a tuft of hair, cord and dysplasia of the spinal cord are the causes a dermal vascular malformation, or an obvious of these disparities and they may actually extend subdermal lipoma [8]. Alterations may be found in the several segments above and below the actual site of arrangement or configuration of the toes, along with the myelomeningocele. Therefore urodynamic and discrepancies in lower extremity muscle size and functional classifications have been more practical strength with weakness or abnormal gait. Back pain for defining the extent of the pathology and planning and an absence of perineal sensation are common treatment in children. The detrusor and sphincter are two units working in Incidence of abnormal lower urinary tract function in harmony to make a single functional unit. This can lead to Determined by the nature of the neurologic deficit, changes in bowel, bladder, sexual and lower extremity they may be either in an overactive or in an inactive function. The detrusor may be overactive with increased contractions, with a diminished bladder capacity and Sacral agenesis is a rare congenital anomaly that compliance or be inactive with no effective coninvolves absence of part or all of one or more sacral tractions; the bladder outlet (urethra and sphincter) may vertebrae. Perineal sensation is usually intact and be independently overactive causing functional lower extremity function is usually normal and the obstruction or paralyzed with no resistance to urinary diagnosis is made when a flattened buttock and a flow leading stress incontinence. Detrusor overactivity with overactivity of the sphincter ultrasound and cystography should also be done. Detrusor overactivity with normal or underactivity of the upper and lower urinary tracts, can facilitate the of the sphincter, diagnosis of hydronephrosis or vesicoureteral reflux, and can help identify children at risk for upper urinary 3. Detrusor underactivity with sphincter overactivity tract deterioration and impairment of renal function. Grade of recommendation: B Sometimes this is more helpful, as the detrusor may be overactive during filling, but underactive during Overwhelming experience gained over the years with ‘voiding’. Presence of overactivity birth in all babies and especially in those with signs during filling with or without decreased capacity and of possible outlet obstruction [23-27]. Grade of recommendation: B overactivity of the sphincter and failure to relax during the early initiation of intermittent catheterization voiding. A lower motor neuron lesion is considered in the newborn period, makes it easier for parents to when the detrusor contractions are weak or lost and master it and for children to accept it as they grow older the sphincter is underactive. With early management not only are upper tract changes less, but also bladders are better protected Evidence level 3. For the very young child the combination of an It has been suggested that increased bladder overactive detrusor and sphincter is potentially pressures due to detrusor sphincter dyssynergia dangerous because of the high intravesical pressures, cause secondary changes of the bladder wall. These which will put the upper tract at risk (vesicoureteral fibroproliferative changes in the bladder wall may reflux and hydronephrosis), whereas an underactive cause further loss of elasticity and compliance: detrusor and paralysed sphincter is relatively safe, resulting in a small non-compliant bladder with providing a low-pressure reservoir [15-17]. It is believed that early institution of intermittent catheterization and Level of evidence: 2 anticholinergic drugs may prevent this in some patients [30-32]. When combined with obvious detrusor contractions are unlikely to respond newer and more potent antimuscarinic drugs to this treatment. Some clinical studies are available, but no In a single study urethral sphincter botulinum-A toxin randomised placebo controlled studies have been injection has been shown to be effective in decreasing performed [31,37-41]. The evidence A prospective controlled trial evaluating trospium in is still too low to recommend its routine use in children reports that trospium is effective and safe in decreasing outlet resistance, but it could be considered correcting detrusor overactvity in children but this as an alternative in refractory cases [58]. Its practice is limited to a few extended release formulation of tolterodine is found centres who have reported varying results. The nature to be as efficient as the instant release form with the of this type of treatment (time consuming and very advantages of being single dosage and less expensive dedicated personal) does not make it attractive for [43]. Grade of recommendation C Use of medication in children with neurogenic bladder Children with neurogenic bladder also have to facilitate emptying has not been studied well in the disturbances of bowel function. Few studies investigating the use of alphain these children is frequently unpredictable; it is adrenergic blockade in children with neurogenic related to the loss of lower bowel sensation and bladder report good response rates but they are nonfunction, altered reflex activity of the external sphincter controlled studies and long-term follow-up is lacking and the consequent failure to fully empty the rectum [44-46]. Level of evidence 4 the majority of children with a neurogenic bladder also have constipation and this is managed most Use of intravesical oxybutynin in children with poorly commonly with laxatives, such as mineral oil, compliant neurogenic bladder has been investigated combined with enemas to facilitate removal of bowel in some studies and incontinence has been shown to contents. A regular and efficient bowel emptying be improved significantly in most studies, with “dry and regimen is often necessary to maintain fecal improved” rates ranging from 61% to 83% [47]. Use continence and this may have to be started even at of lidocain intravesically also has been shown to be a very young age. With antegrade or retrograde effective to improve bladder capacity and compliance enemas, the majority of these children’s constipation and decrease overactivity in children with neurogenic can be managed and they may attain some degree bladder [48]. Grade of recommendation: C external anal sphincter have not been shown to be In neurogenic bladders that are refractory to more effective than a conventional bowel management antimuscarinics and still remain to be in a small program in achieving fecal continence [66]. Electrocapacity and high-pressure state, injection of stimulation of the bowel may also offer a variable botulinum toxin into the detrusor has been introduced improvement in some patients [67]. Grade of recommendation D promising results in adults have also initiated its use in children. So far pediatric studies have been openUrinary tract infections are common in children with label studies and prospective controlled trials are neurogenic bladders. Injection of botulinum toxin in therapy with urinary tract infections should be treated if resistant bladders seems to be an effective and safe symptomatic. This treatment seems to be antibiotics to patients with bacteriuria without clinical more effective in bladders with evidence of detrusor symptoms [68-71]. Grade of recommendation B failure usually progresses slowly but may occur with Patients with vesicoureteral reflux and urinary trac startling rapidity in these children. Patients with myelodysplasia have sexual encounters, and studies Intermittent catheterization and drug therapy are indicate that at least 15-20% of males are capable of usually sufficient in the majority of cases for maintaining fathering children and 70% of females can conceive continence and preserving upper tracts. Therefore counseling procedures should be considered if conservative patients regarding sexual development is important measures fail to achieve continence between in early adolescence.

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Ironically medications in pregnancy cheap duphalac 100 ml otc, the many medical challenges and ultimate loss of others in this close network can be threatening to treatment 3rd degree hemorrhoids 100 ml duphalac visa other families and can add to symptoms 9 days after embryo transfer discount duphalac 100 ml free shipping the cumulative losses experienced by this unique group medicine 93 2264 purchase cheap duphalac online. It is an emotional, physical, and spiritual necessity, the price you pay for love. In my experience, anti-depressants and even therapy did not help (although both can help many). I fnally concluded that I owned this grief, and if life could ever become more bearable, I had to walk right through the middle of the most painful feelings imaginable. I had to cry (incessantly, my husband would say), and I had to express my deepest feelings if a special friend would listen. I also had to fnd those caring family members, friends, and physical activities that would bring positive energy to my life. I had to walk, immerse myself in the beauty of nature, ski down a mountain, and listen to the classical music that brought peace and joy into my life. Some fnd comfort in creative and artistic pursuits, in journaling, in prayer, and in meditation or mindfulness. Reaching out to people in need or devoting energy to a cause that serves others can be therapeutic. Many parents affrm that their religious beliefs have been crucial to their emotional survival. And yet some get “stuck” in the grieving process and fnd it extremely diffcult to function over an extended period of time. In these situations, professional help may be essential to move through the most painful phases of grieving. This 360 Chapter 19: the Grieving Process and the Physician’s Role: A Mother’s Perspective is very rarely the case. Over a period of months and even years, the pain one initially experiences will lessen. Parents fnd increased energy to engage with other people, to work with energy and purpose, and to follow new pursuits. But I believe that when a parent loses a child, the parent never really “gets over” the loss. The special relationship you cherished, the precious time you shared, and the essence of the one you lost is forever a part of you. And in spite of your suffering, you might well admit that you were truly fortunate to be the parent of this wonderful human being. Many acknowledge that, in spite of what they and their child have been through, they would forever choose the time they had, than never to have known this child at all. The hole in my heart shall always remain, but there is healing around that hole, and I carry my daughter in my heart, always. How physicians can help A patient’s physician is not expected to “treat” the emotional distress of the grieving parents or spouse, although it may be appropriate for the physician to refer the parents or spouse to a support group, grief counselor, or other professional in one’s local community. The patient’s physician, however, has enormous power to affect the emotional state of the family caregivers. The physician can play a crucial role in helping the family move from the depths of despair, anger, and self-blame into understanding the disease, making and participating in a treatment plan, and maintaining hope. The treating physician needs to be willing to learn, eager to explore current literature and to seek out information from experts. The doctor must be willing to invest the time to learn new therapeutic approaches. It is extremely helpful if the physician is a caring, warm individual, concerned about the welfare of the patient and aware of the stress the family is experiencing. Physicians need to listen to fears and concerns, and answer questions in understandable terms. It is crucial that they give families the time they need to ask questions, and listen to their concerns and feelings. Physicians may be helpful in encouraging the family to ask diffcult questions that fear may cause family members to avoid. It is all right for doctors to admit they don’t know all the answers and to assure families that they will try to fnd out. Richard Sills, sat down with us very late one night explaining, reviewing, and answering every single one of our questions and fears. Statistics do not include the high probability that bone marrow transplant outcomes will continue to improve, that new methods of gene therapy could change life expectancies, and that future discoveries will improve overall survival rates. Families need to know that scientifc discoveries concerning this rare disorder have progressed at a very rapid pace over more than a decade and that many laboratories are actively pursuing new and hopeful approaches. They can unwittingly create an atmosphere of sadness and worry which permeates every day and which children immediately sense. As a result, the time that is shared between parent and child may not be “quality time” at all. By emphasizing progress and helping to instill hope, physicians can greatly assist in improving the family’s quality of life. Entering into a partnership with families Family members should be encouraged to play an active role in the treatment plan. Making families part of the decision-making process enables them to cope with the anxiety, depression, and loss of control they are experiencing. The relationship between physician and family should be one of mutual respect, shared information, and joint decision-making. Caretakers know the patient well and are aware of subtle or abrupt changes in the patient’s condition. The doctor should encourage family members to voice their concerns or disagreements with the treatment plan. Parents and patients are often intimidated by medical authority, or fear appearing foolish by asking inappropriate questions. But they must live with the results of any medical intervention, so they must understand and agree with decisions. Family members must believe that the most appropriate decisions were made, given what was known at the time. When they are ill-informed and have never voiced their questions or concerns, they may forever feel guilty if the outcome is not good. Being responsive to patient needs A doctor’s responsiveness and empathy with the patient helps foster a good relationship with other family members. When the physician is warm, caring, and concerned about the patient, parents feel positively towards that provider. Whether the patient’s immediate concerns are about pain, nausea, fear, or side effects of treatment, these concerns need to be addressed in a caring manner. I believe that a great deal of pain can be eliminated when pain management is 363 Fanconi Anemia: Guidelines for Diagnosis and Management a priority. Bone marrow aspirations and biopsies can be performed under very short-term, general anesthesia, leaving the patient with a less painful experience. But outpatient clinics, aware of the importance of this issue, may be able to offer the same service. Even though total anesthesia is more costly and the assistance of an anesthesiologist is mandatory, the children and adults who must experience these procedures on a regular basis should not have to endure unnecessary pain. However, in many cases in which patients are not provided with total anesthesia, it is simply because it is not suggested or offered by the physician or care facility, not because it is unavailable. Communicating diagnostic results promptly Family members experience much agonizing distress while waiting for the results of clinical tests. The treating physician should make sure that family members get crucial information as soon as possible. Encourage normalcy When appropriate and within prudent medical guidelines, physicians should encourage patients to live as normally as possible. Sometimes it is necessary to curtail physical activity, but simple measures such as a protective helmet or other modifcations might make normal activities possible. When platelets are so low that participating in any contact sport is not wise, there may still be a role for a child in assisting the coach, thereby maintaining involvement with the team. Consideration should always be given to maximizing the quality of a patient’s life. Being “there” for a family when a patient’s condition worsens When a patient’s condition worsens suddenly or when he or she approaches death, a physician should not suddenly withdraw from the family. They suspect that doctors need to protect 364 Chapter 19: the Grieving Process and the Physician’s Role: A Mother’s Perspective themselves from the family’s emotional response and the physician’s own feelings of grief. But families desperately need support at this time, and are deeply grateful when physicians are able to empathize with them during the hardest times.

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You have completed the history and physical exam medications 3 times a day effective 100 ml duphalac, and it is now time to medications ritalin generic 100 ml duphalac with visa present your findings to symptoms lead poisoning discount duphalac american express your preceptor medications post mi 100 ml duphalac overnight delivery, focusing on pertinent positives and negatives. He is presenting today for a well child visit, but you were able to elicit a 3-month history of fatigue, irritability and decreased exercise tolerance. He is a picky eater, with excess intake of milk and juice, with little intake of iron-rich foods. He has no history of radiation exposure, medications or chronic disease, and no family history of blood disorders. He has no features on history suggestive of a hemolytic process such as jaundice or dark urine. On exam, he is mildly tachycardic, with a 2/6 systolic ejection murmur at the Left Upper Sternal Border. At 18 months of age children are walking and falling and this type of bruising is common. However, I do think this case would warrant investigation, so let’s move on to the work-up for a child with anemia. Investigations and Diagnostic Approach Chris: With such a broad differential for anemia, the list of possible investigations is vast. Forbes, how do you approach ordering investigations for a child with suspected anemiafi Once you know how many red blood cells you have, there are further indices, which tell you more about the size of the cells and the concentration of hemoglobin in each cell. Smaller red cells are described as microcytic, while bigger red cells are described as macrocytic, represented by lower or higher numbers respectively. Normal ranges vary significantly with age, particularly in infancy so it is important to ensure that you are using age and sex adjusted normal values. A link to the reference ranges used in Alberta is included in the supplementary materials on PedsCases. First, at birth hemoglobin is quite high, as a result of the relatively low oxygen state in utero. This higher hemoglobin that is present in the first days-weeks of life gradually declines as fetal hemoglobin, or HbF is replaced with adult-type hemoglobin, or HbA. This results in a normal decline in hemoglobin, or what is called the physiologic nadir, around 2 months of age. After this, hemoglobin steadily increases until about age Developed by Chris Novak and Dr. You should also look at white blood cell and platelet numbers to assess if this is an isolated anemia, or is suggestive of a more concerning pancytopenia. Using these different indices, combined with your history and physical you will be able to point yourself towards a more specific etiology. Iron deficiency is the most common cause of microcytic anemia, but it is important to consider other options in your differential. The differential for microcytic anemia may be commonly remembered by the acronym “I See the Little Cells”: I – Iron Deficiency Anemia S – Sideroblastic anemias T – Thalassemias L – Lead toxicity C – Anemia of Chronic Disease Hemoglobinopathies or disorders of abnormal hemoglobin can also cause microcytic anemia with the exception of sickle cell anemia. Normocytic Anemias have normal sized red blood cells, but you just don’t have enough of them. The differential for normocytic anemia includes problems of bone marrow suppression, red blood cell destruction and loss. To differentiate the etiology of normocytic anemia you will likely need additional lab testing. It is important to go back to your history to explore the possibility of chronic disease. Macrocytic anemias are rare and the least common type of anemia seen, and result in the production of abnormally large red blood cells. It’s important to remember that newborn, and especially preterm infants have larger red blood cells than normal, but this is part of normal development, and they will decrease in size with time. Pathologic causes of macrocytic anemia include: B12 and folate deficiency most commonly, but also Some medications Hypothyroidism Some hereditary conditions And other bone marrow disorders Developed by Chris Novak and Dr. Forbes: the ordering of further tests should be based on your history and physical leading you to suspect a specific cause of anemia. Do not just take a shotgun approach and order a test for every possible cause of anemia. While there are many possible tests you could order, here are a few important ones to consider. This can tell you what the cell looks like, and a number of abnormal morphologies, which can point towards a diagnosis. While specific interpretation of the peripheral smear is beyond the scope of this podcast, a smear is indicated when you suspect malignancy, a hemoglobinopathy or hemolysis. When the bone marrow is under stress and is actively producing new red blood cells, immature red blood cells called reticulocytes are released into the circulation. If the reticulocytes are low or normal, this would be an inappropriate response, as the bone marrow is not responding. This means that the anemia is either due to a “Destruction” process or blood “Loss” as discussed previously. You should suspect a hemolytic anemia if you have a suggestive history, observe jaundice on physical exam, or have an appropriately elevated reticulocyte count with no obvious causes of blood loss. A hemoglobin electrophoresis is required to diagnose a hemoglobinopathy and is one of many other tests could be ordered to identify a specific etiology. However, a stepwise approach is always best and if you start with the basics, you should be well on your way to making a diagnosis. Ferritin represents iron stores, but is also an acute phase reactant, which means it is often elevated in the context of an infection or inflammation, which is often when we see children and note the anemia on blood work. Where iron studies can be helpful is when a patient’s anemia is seemingly not responsive to iron therapy, or if there is concern that iron deficiency is contributing in a patient who has another reason for anemia, such as in thalassemia. You recall from your history that Sam has a diet low in iron, with a high intake of milk and juice. You review with your preceptor and they agree that the most likely diagnosis would be iron deficiency anemia. Given the ethnic background of this patient, you would also want to keep in mind the possibility of thalassemia. Anemia has a huge differential, and the management for each different disease process is quite different. A detailed discussion of all of the different types of anemia is beyond the scope of this podcast, but we would like to discuss two points: Iron Deficiency Anemia and Indications for Transfusion. Iron is one of the critical building blocks for hemoglobin and without it you cannot produce sufficient red blood cells. Without enough iron to fill up the red blood cells, they present as small, shrunken or microcytic. At birth children have adequate iron stores and they are able to live exclusively on breast milk or formula without developing iron deficiency. Beyond 6 months, these stores start to run out and iron-containing foods need to be introduced into the diet. Often these children are described as “picky” eaters and drink excessive amounts of milk, which fills them up and contributes to a lack of appetite for iron containing solids. If the child is clinically stable, less than 2 years of age, has risk factors or a dietary history in keeping with iron Developed by Chris Novak and Dr. June 11, 2015 deficiency, and another cause does not seem more likely, you can empirically treat with oral iron supplementation. If the hemoglobin has increased >10 g/L, this confirms the diagnosis of iron deficiency anemia. In my experience, hemoglobin often increases and can return to normal fairly quickly, however you still need to continue iron supplementation for at least 3 months to ensure you replenish iron stores. In older children, or children without a history consistent with iron deficiency, or children who fail to respond to empiric oral iron, a more thorough diagnostic work-up would be indicated to help elucidate the cause of the anemia. This would likely include a peripheral blood smear, iron studies and potentially other tests such as hemoglobin electrophoresis or fecal occult blood testing as appropriate.

The main causes are iron deficiency and thalassaemia and sometimes anaemia of chronic disease medicine vs nursing discount duphalac 100 ml amex. The red cells are of normal size and have normal Hb concentration or they can be of varying sizes but average is normal medications for migraines buy duphalac with american express. Causes of this can be blood loss medications that cause tinnitus generic 100 ml duphalac with amex, haemolytic anaemia medications vs medicine purchase 100 ml duphalac, secondary anaemia and mixed deficiency anaemia. Causes of this can be B12/folate deficiency, liver disease, hypothyroidism, cytotoxic drugs and myeloma. The monograph features basic information necessary to understand and appreciate the importance of hematology testing in the laboratory and is intended for those who work and use the hematology laboratory services. These individuals include, but are not limited to, laboratory technicians, laboratory technologists, laboratory supervisors and managers, nurses, suppliers, and other physician ofce and laboratory support personnel. Recognize physiologic features of the body in which blood plays an important role 2. The generation, movement, metabolism, and storage of body fuids are balanced through complex interlocking chemical processes and feedback controls. This balance, called homeostasis, is a dynamic but steady state maintained by the constant expenditure of energy from cellular metabolism. Interstitial fuid surrounds and bathes cells and is the medium for exchanges of nutrients and wastes between the blood and the cells. To perform their work, cells must receive oxygen and nutrients (carbohydrates, proteins, fats, water, minerals, and vitamins). The digestive system supplies the nutrients, and the respiratory system supplies the oxygen. The cardiovascular system (heart, blood vessels, and blood) is the delivery system. Note, however, that due to variations in individuals, normal values are almost always given in ranges. Normal ranges may vary somewhat from one source to another and may be reported in a variety of units. Hematology usually refers to the study of gross features of blood such as cell counts, bleeding time, etc. Metabolism metabolic reactions take place Dynamic steady state maintained by constant expenditure of body B 2. Match the following actions and reactions to the body chemicals: A Energizers and sources of energy 1. Electrolytes F Gatekeepers that allow movement of substances through cell walls 6. Identify the chief characteristics of red blood cells, white blood cells, and platelets 4. It distributes oxygen, nutrients, electrolytes, hormones, and enzymes throughout the body. Plasma, which makes up about 55% of blood, is the strawcolored clear liquid in which cellular elements and dissolved substances (solutes) are suspended. Products of metabolism: urea, uric add, creatine, creatinine, ammonium salts; toxic if not removed; carried in blood to organs of excretion Products of digestion. Enzymes for cellular chemical reactions; hormones to regulate growth and development Electrolytes. Cell Types Found on Blood Smears from Normal Individuals Most blood samples are measured in microliters (µL); to give you a reference, a drop of blood is roughly 30 µL. A blood clot is formed when sticky platelets become covered with fbrin – a plasma protein that holds the blood clot together. Each of the formed elements of blood will be covered in more detail in the following sections. Stem cells in bone marrow continuously proliferate – usually at a steady state to maintain a constant population of mature blood cells. As they age and mature, they become smaller and change in their reaction to the dyes used to stain them for identifcation. Located beneath the diaphragm and behind the stomach, the spleen is an intricate flter that receives 5% of the total blood volume each minute. In the embryo, the spleen is a blood-forming center; it loses this function as the fetus matures. Because it is not essential to life, the spleen may be removed (splenectomy) without serious efects. A cell with basophilic staining properties is a cell that stains specifcally with basic dyes; a cell with eosinophilic staining properties is a cell that stains with eosin, a red acidic dye. Poor absorption of vitamin B12 is due to lack of secretion of intrinsic factor by the gastric mucosa. Accurate ferritin measurement often reveals iron-defcient anemia before other laboratory values change. Anemias due to defcient rbc formation: normochromic-normocytic anemias Anemia Due to Renal Failure. Hemolysis (lysis = break down) is a process in which red cells fall apart and spill out their hemoglobin. Anemia arises when hemolysis occurs in response to a number of factors: spleen dysfunction, immunologic abnormalities, trauma, blood transfusion reactions, malaria, use of some therapeutic drugs, exposure to toxic chemicals, or infections. This serious condition is present in about 1% of West African and American Blacks. A patient with cardiac failure is also likely to develop this condition; the inefcient heart is not able to deliver enough oxygenated blood to tissues. The agglutination may be mild and transient or may progress into a disease called “cold antibody disease” or “cold agglutinin disease”. Caused by radiation exposure 5 A probable cause for hypochromic-microcytic anemia is: A. Thalassemia 6 A pregnant patient who practices strict vegetarianism may be a candidate for: A. As a granulocyte matures, the cell nucleus undergoes many changes; it shrinks, indents, assumes a band form, and segments. Neutrophils seek out and kill bacteria – a process called phagocytosis (see below). Eosinophils attack some parasites and inactivate mediators released during allergic reactions. Monocytes granules, occasional azurophilic with linear chromatin deeply indented nucleus granules, and vacuoles in cytoplasm Process Foreign substances (antigens) invade Plasma factors (including lymphocytes and basophils) attract phagocytes to Chemotaxis the invaded area Plasma factors (immunoglobulins) coat antigens to make them “tasty” for Opsonization phagocytes Phagocytes bind to and ingest antigens. Monocyte with appearance, evenly distributed fineAfter a short time in the blood, monocytescytoplasm, lobulation of nucleus(Figure 6)prominent granules andenter tissue, grow larger, and become tissue 7D. Once it was incorrectly thought that endothelial cells (cells lining blood vessels) performedindentations cytoplasm, band type of nucleus, cytoplasm, blunt pseudopods, and granules, and vacuoles in cytoplasm the same function as macrophages. Monocyte with vacuoles, indentations cytoplasm, band type of nucleus, cytoplasm, blunt pseudopods, andtype nucleus nongranular pseudopods, nuclear nongranular ectoplasm, and linear chromatin, blunt pseudopods, multilobulated nucleus indentations, and folds granular endoplasm and fine granules Figure 6. Monocyte with appearance, evenly distributed fine cytoplasm, lobulation of nucleus prominent granules and granules, occasional azurophilic with linear chromatin deeply indented nucleus granules, and vacuoles in cytoplasm 7D. Monocyte with gray-blue indentations cytoplasm, band type of nucleus, cytoplasm, blunt pseudopods, and linear chromatin, blunt pseudopods, multilobulated nucleus and fine granules 7G. Monocyte with vacuoles, type nucleus nongranular pseudopods, nuclear nongranular ectoplasm, and indentations, and folds granular endoplasm Figure 7. Within a few hours, the second line of defense appears: the number of neutrophils in the blood increases substantially as substances in the blood stimulate bone marrow to release stored neutrophils. The third line and the long-term chronic defense is the proliferation of macrophages by cell reproduction in the tissue, by attracting monocytes from the blood, and by increased production of monocytes. Free macrophages: large wandering cells Spleen, lymph nodes, lungs,many other tissues Circulating monocytes: large, motile cells with Blood indented nuclei Table 5. T cell receptors allow them to interact with macrophages and other cells and substances in the body. Through a variety of T cells (helper T cells, suppressor T cells), the body initiates, carries through, and terminates antigen-antibody reactions to provide immunity.

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