By L. Farmon. University of New Mexico. 2018.
Thrombocytopoiesis Other Bone Marrow Cells The developmental stages involved in thrombopoi- Other cells frequently encountered in bone marrow esis are the thromboblast purchase 10 mg escitalopram, early-immature thrombo- samples include osteoclasts order 5 mg escitalopram with visa, osteoblasts, monocytes, cyte, mid-immature thrombocyte, late-immature plasma cells and mitotic figures. The abundant cytoplasm is weakly basophilic decreases, the N:C ratio decreases, the nucleus be- and often contains vacuoles and small red granules comes increasingly pyknotic and cytoplasm becomes of various shapes. The oval-to-round Thromboblasts are large, round-to-ameboid-shaped nucleus is eccentrically positioned in the cell. The cells with a narrow rim of deeply basophilic cyto- abundant, foamy, basophilic cytoplasm contains a plasm surrounding the round nucleus. The nuclear prominent clear space (Golgi) that is located a dis- chromatin often appears punctate, making nucleoli tance from the nucleus. The early-immature thrombocyte is smaller than the Products Mentioned in the Text thromboblast. Coulter Counter, Coulter Electronics, Inc plasmic granules may be seen at this stage. Res Vet Leucocytozoon smithi infection of tur- Proc Assoc Avian Vet, 1984, pp 229- 26. Taylor M: Polycythemia in the blue tally produced hemolytic anemia in cal haematology of captive cranes 54. J Assoc Avian Vet cular and hematologic effects of hem- nal cholesterol, and differential leuco- University Press, 1988, pp 257-336. The basic cytodiagnosis of inflammation, tissue hyperplasia, malignant neoplasia and normal cellu- larity are easily differentiated from each other (see Figures 10. One who is well versed in mammalian cytodiagnosis should have little trouble in the interpretation of avian samples. The goal is to 10 achieve a quick presumptive or definitive diagnosis during the patient’s initial visit to the veterinary clinic in an effort to provide an immediate and spe- cific treatment plan. Cytology can then be used to monitor the success of therapy by evaluating changes in microbial and cell populations within or on the host. Cytology should be considered as a part of the minimum database in birds with discharges, masses or swellings. Cytological samples are of greatest value if they are collected fresh and immediately processed for evaluation. To obtain a cytologic sample and send it to an outside laboratory defeats the purpose and usefulness of cy- Terry W. This will serve to improve understanding of the pathogenesis and cellular effects of a disease process. The needle is moved at different angles in the tissue without releasing the vacuum. It is impor- Sample Collection tant to release the vacuum before withdrawing the needle from the tissue, because the aim of the proce- dure is to obtain a small amount of sample in the lumen of the needle only, not in the syringe itself. A variety of sample collection methods can be used to Once the needle has been withdrawn from the tissue, obtain samples for cytologic examination. Cytologic sample inge, and with the point of the needle lying against collection methods can be divided into two broad the slide surface, the air within the syringe is used to categories: aspiration and contact smears. A second glass microscope slide placed on top of the first allows the sample to spread between the two Sample Collection by Aspiration glass surfaces when the slides are pulled horizontally Fine-needle aspiration biopsy is a simple, inexpen- apart. Two specimens for cytologic examination are sive procedure for obtaining material for cytologic thus created. Using an alcohol swab, the “squash preparation technique” because the sam- the skin overlying the biopsy site is cleansed and ple is compressed between the two slide surfaces. A hypodermic needle (eg, 22 ga, Abdominocentesis is an aspiration biopsy procedure one-inch needle) attached to a syringe (12 ml or used to collect cytologic samples from birds with larger) is inserted into the tissue to be sampled. The abdominal space vacuum is applied to the syringe using the syringe is small in normal birds and contains little fluid. Because the abdominal air sacs occupy a large por- tion of the abdomen, it is difficult to enter the perito- neal cavity of normal birds. However, as peritoneal fluids accumulate, the air sacs are compressed later- ally, increasing the size of the peritoneal cavity and making it easier to sample. Abdominocentesis begins with a surgical preparation of the site along the ventral midline just distal to the point of the keel. The needle (21 to 25 ga, one-inch) is attached to a syringe and is directed through the body wall at the midline, pointing toward the right side of the abdo- men to avoid the ventriculus, which lies to the left of the midline (Figure 10. The abdominal fluid is aspirated into the syringe and prepared for cytologic examination, either by making a direct smear as one would prepare a blood film or by using a concentra- tion method. The goal of abdominocentesis is to collect fluid from the abdominal cavity for diagnostic purposes. The material that is collected (eg, gut contents, unwillingness to fly and depression. The hen had been incubating egg yolk, cells from a mass) should be evaluated with eggs, and it was uncertain how long she had been clinically symp- respect to its potential source. The masses in areas where the skin avian species (macaws) will produce small quantities was thin appeared grossly as small, white-to-yellow nodules. Cy- of fluid in response to egg-related peritonitis, while tologic examination of a fine-needle aspirate from the mass re- others (cockatiels) will produce voluminous fluids. Articular gout is common in birds that become dehydrated or that have primary or secondary renal disease. The fluid is placed in a plastic test tube and centrifuged at 600 G (gravity) for ten minutes. Unlike urine sediments, cytologic sediments from poorly cellular fluids do not have a visible button or pellet at the bottom of a spun tube. Therefore, the concentrated cells are usually obtained by aspirating the fluid at the bottom of the tube into a pipette or syringe. The sample is then placed onto a microscope slide and a smear is made in the manner described for concentrating cells in a smear. Special cytocentri- fuge equipmenta is available for concentrating cells on microscope slides while absorbing the fluid onto filter paper. This equipment is expensive and not practical for the average veterinary laboratory. Because centrifugation distorts the appearance of the cells, a cell concentration method that utilizes gravity provides a concentrated sample with normal appearing cells. A simple, inexpensive sedimentation device can be made for use in the veterinary labora- tory. This device consists of a base to support the slide and a clamping mechanism to hold the fluid column onto the microscope slide (Figure 10.
Other popular botanical medicines include pygeum (Pygeum africanum) discount escitalopram 10 mg on line, stinging nettle (Urtica dioica) escitalopram 10mg overnight delivery, and Cernilton, a special ﬂower pollen extract. On the basis of careful examination of the published literature, we rate saw palmetto as the most effective, followed by Cernilton, pygeum, and stinging nettle. However, each plant has a slightly different mechanism of action, and one herb may work better for a particular person than another herb. Residual urine levels between 100 and 150 ml will make it tougher to see signiﬁcant improvements. If the residual urine content is greater than 150 ml, saw palmetto extract and other botanical medicines are unlikely to produce any significant improvement on their own. Over the years many of us in the natural health ﬁeld have seen the media disseminate questionable results from research studies in major medical journals, holding them up as “proof” that the public is being duped into spending money on worthless natural products. Of course, those knowledgeable about the merits of these same natural products try to mobilize the resources that we have available to counteract these negative statements, but this is often difﬁcult when we are up against an article published in a respected journal such as the New England Journal of Medicine, Lancet, British Medical Journal, or Journal of the American Medical Association. Such journals are seemingly more credible than even the natural product industry’s most reputable organizations, companies, and experts. The problem is that the study that got a lot of publicity was done in men with severe, advanced disease, in which saw palmetto is already known not to work. The media did not make this distinction, simply asserting that saw palmetto does not work. If a man waits until his prostate has enlarged so severely that it results in signiﬁcant obstruction of the bladder, saw palmetto is simply not likely to work. But if he starts it early enough, it is as effective as or more effective than popular prescription drugs without the side effects. Adverse effects from the saw palmetto extract were mild and infrequent, with erectile dysfunction appearing more frequently with ﬁnasteride (4. Future studies will hopefully include head-to-head trials comparing saw palmetto with alpha-blockers such as tamsulosin (Flomax), doxazosin (Cardura), and prazosin (Minipress). In addition, Cernilton contains a substance that inhibits the growth of prostate cells. They saw improvements in average urine maximum ﬂow rate, average ﬂow rate, and residual urine volume. Overall, 85% of the test subjects experienced beneﬁt: 11% reporting “excellent,” 39% reporting “good,” 35% reporting “satisfactory,” and 15% reporting “poor” as a description of their outcome. A summary review of two placebo-controlled studies, two comparative trials (both lasting 12 to 24 weeks), and three double-blind studies of 444 men showed that although Cernilton did not improve urinary ﬂow rates, residual volume, or prostate size, it did improve self-rated urinary symptom scores and reduced nighttime urinary frequency compared with a placebo and an amino acid mixture. Pygeum The bark of Pygeum africanum, an evergreen tree native to Africa, has historically been used in the treatment of urinary tract disorders. Virtually all of the research on pygeum has featured an extract standardized to contain 14% triterpenes, including beta-sitosterol and 0. This extract has been extensively studied in both experimental animal studies and clinical trials with humans. A study on rat prostatic cells suggests that the therapeutic effect of pygeum may be due in part to the inhibition of growth factors (e. However, there may be circumstances where pygeum is more effective than saw palmetto. For example, saw palmetto has not been shown to produce some of the effects on prostate secretion that pygeum has. Of course, as the two extracts have somewhat overlapping mechanisms of actions, they can be used in combination. Fewer studies have been done with stinging nettle root extract than with the other botanical medicines discussed. A randomized, multicenter, double-blind study of 431 patients using both the extracts of saw palmetto and stinging nettle found clinical beneﬁt equal to that of ﬁnasteride. It is important to limit the consumption of meat and other animal products; alcohol and coffee; drug-, pesticide-, and hormone-contaminated foods; and cholesterol-rich foods. It affects few blacks in tropical zones but is more common among blacks in temperate zones. It appears commonly among Japanese but is rare in American Indians and is entirely absent in natives of the Andean region of South America. The nails take on a characteristic thimble-like appearance referred to as “oil drop” stippling. Causes Psoriasis is caused by a pileup of skin cells that have replicated too rapidly. The rate at which skin cells divide in psoriasis is roughly one thousand times greater than in normal skin. This high rate of replication is simply too fast for the cells to be shed, so they accumulate, resulting in the characteristic silvery scale of psoriasis. The frequency of psoriasis is increased in people with certain genetic markers, reﬂecting a possible genetic error in the control over how skin cells divide. The genetic link is also conﬁrmed by the observation that 36% of psoriasis patients have one or more family members with psoriasis. There are also multiple defects noted in the skin and immune cells of psoriatic patients, indicating a complex interplay of genetic factors. It appears that rather than being a disorder of the skin cells, psoriasis is primarily a condition that affects the immune system. There is a clear relationship between psoriasis and conditions associated with altered gastrointestinal permeability, such as celiac disease10 and Crohn’s disease, 11 and in conditions associated with impaired liver function. Therapeutic Considerations Although psoriasis has a signiﬁcant genetic component, addressing the factors that can activate the immune system or skin cells can result in significant clinical improvement. Incomplete Protein Digestion Incomplete protein digestion or poor intestinal absorption of protein breakdown products can result in elevations of amino acids and polypeptides in the bowel. In particular, toxic metabolites of the amino acids arginine and ornithine, known as polyamines (e. These polyamines have been shown to contribute to the excessive rate of cell proliferation in psoriasis.
Finally cheap escitalopram 5mg without prescription, myocardial infarction may Patients with severe renal dysfunction also appear to be recognized escitalopram 10mg fast delivery, usually after the patient succumbs. As have better outcomes when several courses of thera- with most idiopathic vasculitides, there is no diagnos- peutic plasma exchange are used . Possible laboratory findings patient will be treated with cyclophosphamide for 6 include elevated erythrocyte sedimentation rate, ele- months with the dose adjusted to prevent neutropenia vated serum immunoglobulin concentrations, and, not (a particular problem in patients with renal failure). Those patients who require prolonged ther- A systemic illness characterized by the presence of either a apy to retain remission may benefit from a switch to biopsy showing small and mid-size artery necrotising vasculitis a less toxic agent, such as azothiaprine. Therapeutic plasma exchange has not shown to nodules, other vasculitic lesions) be effective when added to steroids alone or steroids › Myalgia or muscle tenderness plus cyclophosphamide in at least two controlled trials › Systemic hypertension, relative to childhood normative data [32, 33], although there was a trend for improved sur- › Mononeuropathy or polyneuropathy vival in both studies, and the sample size may have › Abnormal urine analysis and/or impaired renal functionb resulted in a type 2 error. Therefore, in a critically ill patient, we still would consider therapeutic plasma › Testicular pain or tenderness exchange at least in the acute phase of the illness. Several reports have shown a positive outcome of therapy with tumor necrosis factor-alpha a Should include conventional angiography if magnetic resonance blockade in patients with chronic disease that failed angiography is negative b to remit with steroid and cytotoxic therapy, includ- Glomerular filtration rate of less than 50% normal for age ing one pediatric patient . Five-year survival at any level [39, 51], and it may be limited to only the untreated is only 13%, but treatment has improved this descending thoracic or abdominal aorta in a minority rate to 80% [24, 26]. In the later stages, the pulmonary artery one half of patients, and addition of a cytoxic agent can also be affected. Therefore, mononuclear infiltrates in all layers, with more general recommendations are to use corticosteroid involved sections containing granulomas with giant therapy initially only for patients with mild disease cells and central necrosis . For lead to narrowing of the branch orifices (accounting children, we recommend 2mg kg−1 day−1 of steroids for the past name of pulseless disease). Treatment of moderately severe disease with tutional symptoms and body aches for weeks to months solid organ involvement should also include either before more significant symptoms occur. Frequently, oral or pulse cyclophosphamide (the latter probably these will include visual disturbance (Takayasu retin- being less toxic but also less convenient), using stand- opathy), focal neurologic deficits, claudication, and ard immunosuppressant dosing (oral 2mg−1 kg−1 day−1 intestinal angina. Of note, with a maximum of 100mg daily or 500–1,000mg blood pressure readings are often lower in the upper m−2 intravenously every month) , titrating dosing extremities compared with the lower extremities to response and keeping absolute neutrophil counts (termed reverse coarctation) because of occlusion of Chapter 17 Vasculitis 243 4. Patients therapies for proliferative lupus nephritis: mycophenolate who survive the first few years could only do so with mofetil, azathioprine and intravenous cyclophosphamide. Dillon M, Ozen S (2006) A new international classification ity of complications at diagnosis, age at onset, and of childhood vasculitis. There is no consensus for following synchronization of plasmapheresis with sub- sequent pulse cyclophosphamide. Surgical intervention or stent placement is nec- Lupus Plasmapheresis Study Group: rationale and updated essary in patients with renovascular hypertension or interim report. Haematopoietic stem cell gene therapy to treat autoimmune Medicine (Baltimore) 52:535–61 disease. Chin Med J (Engl) cell antibodies mediate enhanced leukocyte adhesion 115:705–9 to cytokine-activated endothelial cells through a novel 39. Circulation of good-prognosis polyarteritis nodosa and Churg-Strauss 90:1855–60 syndrome: comparison of steroids and oral or pulse cyclo- 41. Glicklich D, Acharya A (1998) Mycophenolate mofetil Care Med 173:180–187 therapy for lupus nephritis refractory to intravenous cyclo- 44. Am J Kidney Dis 32:318–22 granulomatosis: long-term follow-up of patients treated 29. Arthritis Rheum 42:2666–2673 phosphamide in the treatment of generalized Wegener’s 46. Am J riority of steroids plus plasma exchange to steroids alone Med 67:941–7 in the treatment of polyarteritis nodosa and Churg-Strauss 48. Hellmich B, Lamprecht P, Gross W (2006) Advances in the Heart J 93:94–103 therapy of Wegener’s granulomatosis. Ann Intern vasculitis and renal involvement: A prospective, randomized Med 116:488–98 study. Arthritis Rheum 58:308–17 yarteritis: presence of anti-endothelial cell antibodies and 55. Clin Lupus Erytmatosus, Anaphylactoid Purpura and Vasculitis Exp Immunol 85:14–9 Syndromes. Arthritis Rheum 54:2970–82 pilot trial comparing cyclosporine and azathioprine for 75. Niaudet P, Habib R (1998) Methylprednisolone pulse ther- Ann Intern Med 75:165–71 apy in the treatment of severe forms of Schonlein- Henoch 77. Pediatr Nephrol 12:238–43 renal prognosis of Henoch-Schönlein Purpura in an unse- 61. The Wegener’s Granulomatosis Etanercept Trial Research therapy on rapidly progressive type of Henoch-Schonlein G (2005) Etanercept plus standard therapy for Wegener’s nephritis. Takayasu’s arteritis: correlations of their titers and isotype Scand J Rheumatol 33:423–7 distributions with disease activity. Robbins S, Cotran R, Kumar V, Inflammation - The with special reference to renal involvement. Two months posttransplant, graft dysfunction developed and was found to be caused by obstruction of the transplant ure- more definitive intervention, the ureteral stent was ter at the level of the bladder anastomosis. A ureteral removed during the cystoscopy, and the patient was stent was placed, graft function stabilized (serum cre- monitored closely for recurrence of graft dysfunction, atinine 0. With this support, the patient stabilized and general categorization according to transplant status eventually recovered, including his graft function, and introduced above. Under may affect the patient’s transplant candidacy signifi- all of these circumstances, renal dysfunction can occur, cantly, either by presenting a potential contraindication typically requiring complex management tailored to the to the desired nonrenal transplantation or by establishing specific needs of the individual patient. Some patients with renal dysfunction prior to non- highly multidisciplinary fashion, usually codirected by renal organ transplantation may be expected to recover a combination of intensivists, pediatric subspecialists, kidney function after nonrenal transplantation, likely and transplant surgeons and their teams. Such decisions young recipients of a preemptive transplant from a and plans are examples for the aforementioned complex living adult donor, this complication also appears to multidisciplinary, individualized, and communicative be driven by dramatic decreases in serum osmolality management approach for these patients and require associated with rapid clearance of uremic toxins from thorough consideration of medical prognosis, quality of the circulation when renal graft function is excellent life implications, and other, e. Even in older and bigger recipients, the frequency and volume of urine output measurements and replace- 18. Recovery of tubular abilities to concentrate the urine and reabsorb sodium usually takes several days, over which urine output replacement is gradu- 18. Of critical importance is the realization that the hourly urine output may actu- Table 18. Generally, circumstances, particularly when an adult allograft immunosuppressive therapy is in constant evolution is placed into an infant.
Neuro: alert and oriented discount escitalopram 5mg on line, no focal motor generic escitalopram 5 mg otc, sensory defcits; no neglect with left eye; no facial asymmetry; normal memory; gait normal i. Examination demonstrates unremarkable sclera, conjunctiva, and anterior chamber in both eyes. This is a case of central retinal vein occlusion or blockage of blood fow to the eye. If neurology consultation is attempted, the consultant will defer to the ophthalmologist’s recommenda- tions. Patients should be referred to oph- thalmologist within 24 hours for assessment of possible glaucoma or other pathologies. Optic disc edema and diffuse retinal hemorrhages in all quadrants are patho-Optic disc edema and diffuse retinal hemorrhages in all quadrants are patho- gnomonic for central retinal vein occlusion. Ophthalmoscopic examination reveals dilated and tortuous veins, retinal and macular edema, diffuse retinal hemorrhages and attenuated arterioles. An affer- ent pupillary defect may be noted in the affected eye – loss of vision in that eye prevents light information from being relayed to the brain. Thus, light shone Case 16: Visual impairment Case 17: syncope 89 in the affected eye will not be perceived, and the pupils dilate. When light is directed into the unaffected eye, the information is transmitted to the brain normally, and both pupils receive a signal to constrict. Optic neuritis, though often presenting with similar symptoms as retinal vein occlusion, can be excluded as it is devoid of peripheral hemorrhage on examination. During exercise she developed palpitations and shortness of breath followed by fainting. Social: lives with parents at home, denies alcohol use, smoking, drugs, or sex- ual activity f. Patient remains in ventricular fbrillation/torsades until two shocks and magnesium are administered. Once torsades occurs as in this patient, magnesium sulfate is the drug of choice for conversion, but unstable patients need defbrillation. Postarrest care includes an antiarrhythmic like lidocaine as with any severe arrhythmia. Comfortable appearing male, slightly drooling and sitting upright, holding head and neck still. Circulation: moves all extremities, skin color within normal limits 94 Case 18: sore Throat E. No fever, no cough, no photophobia, no nausea, no vomiting, no abdominal pain noted and no prior episodes noted in him. General: alert, oriented × 3, sitting upright in stretcher, holding head and neck in a fxed position, slightly drooling b. Neck: no stridor, no anterior cervical lymphadenopathy, pain with extension of neck g. Surgery – otolaryngology – assessment shows swelling in soft tissue around the posterior pharynx, normal vocal cords without edema, patent airway. This is a case of retropharyngeal abscess, a serious infection of the soft tis- sue behind the pharynx, which can in severe circumstances lead to a clos- ing of the airway and inability to breath. The patient’s symptoms of drooling, fever, sore throat, and neck stiffness are key fndings. If the candidate does not order antibiotics, the patient will become more short of breath. If surgery or Case 18: sore Throat Case 19: knee Pain 97 otolaryngology is not consulted, the patient will have increased diffculty in breathing and agitation. On physical exam- ination, note the resistance to neck movement (with extension greater than fexion in the midline). Some patients are mistakenly worked up for meningitis because of the neck stiffness. Alternative diagnoses, such as epiglottitis and peritonsillar abscess, must be considered as well. Although a lateral soft tissue neck radiograph is a good initial imaging study, it requires patient cooperation, which can be diffcult in pediatric patients. Otherwise, you may obtain a falsely positive study in which you see widening of the pre- vertebral space as an artifact. The prever- tebral space is widened if it is greater than 7 mm at C2 or 14 mm at C6. The most common organisms are gram positives, specifcally group A Streptococcus and Staphylococcus aureus. Late fndings include extension into the mediastinum, airway compromise from abscess rupture, or direct pressure. Patient appears stated age, obese, limps into the examination room from the waiting room. The pain has been a dull ache for the past 3 months but became more severe after gym class yesterday. He denies trauma, fever, recent respiratory infection, or decreased range of motion to the affected knee. Social: lives with parents and two younger sisters, denies alcohol, smoking, drugs, not sexually active g. General: alert and oriented, comfortable sitting on stretcher, pleasant, cooperative b. Normal knee and ankle examination bilaterally, nontender, no effusion, full range of motion, knees stable to anterior drawer and Lachman test, 2+ dorsalis pedis and posterior tibial pulses bilaterally, normal capillary refll ii. Right hip examination normal, left hip externally rotated; range of motion limited in internal rotation i. Neuro: antalgic gait but otherwise intact motor, sensory, and deep tendon refexes in lower extremities bilaterally j. This is a case of slipped capital femoral epiphysis, the most common cause of hip disability in adolescents. In this injury, the growth plate near the end of the femur becomes disrupted, and the end of the bone “slips” out of place. Important early actions include physical examination of the hips and x-ray imaging of the hips bilaterally including lateral views. If the patient is discharged without a hip exam- ination or x-ray, the patient will return 2 days later unable to walk.