By X. Murak. Mississippi College. 2019.

Most of the problems associated with the Sahli method are due to the instability of acid hematin discount 50 mg solian free shipping, fading of the color glass standard and difficulty in matching it to the acid hematin solution buy solian 50mg amex. HbF is not converted to acid hematin and therefore the Sahli method is not suitable for measuring hemoglobin levels in infants up to 3 months cheap solian 50mg free shipping. Principle 163 Hematology Hemoglobin in a sample of blood is converted to a brown colored acid hematin by treatment with 0 best solian 100 mg. Materials Sahli hemoglobinometer Sahli pipette Stirring glass rod Dropping pipette Absorbent cotton 0. Fill the graduated tube to the '20' mark of the red graduation or to the 3g/dl mark of the yellow graduation with 0. Blow the blood from the pipette into the graduated pipette into the graduated tube of the acid solution. If the color of the diluted sample is darker than that of the reference, continue to dilute by adding 0. Depending on the type of hemoglobinometer, this gives the hemoglobin concentration either in g/dl or as a percentage of 'normal'. Hemoglobin color scale Many color comparison methods have been developed in the past but these have become obsolete because 165 Hematology they were not sufficiently accurate or the colors were not durable. A new low-cost hemoglobin color scale has been developed for diagnosing anemia which is reliable to within 10 g/l (l g/dl). The color of a drop of blood collected onto a specific type of absorbent paper is compared to that on the chart. Validation studies in blood transfusion centers have shown the scale to be more reliable and easier to use than the copper sulphate method in donor selection checks. Copper Sulphate Densitometery This is a qualitative method based on the capacity of a standard solution of copper sulphate to cause the suspension or sinking of a drop of a sample of blood as a measure of specific gravity of the latter and corresponding to its hemoglobin concentration. The method is routinely utilized in some blood banking laboratories in the screening of blood donors for the presence of anemia. Normal hemoglobin reference range: Children at birth 135-195 g/l children 2 y – 5 y 110-140 g/l Children 6 y – 12 y 115-155 g/l Adult men 130-180 g/l Adult women 120-150 g/l Pregnant women 110-138 g/l 167 Hematology Review Questions 1. What are the two most commonly applied color comparison methods for measurement of hemoglobin in a sample of blood? How do you check the linearity of the spectrophotometric method of hemoglobin quantitation in the laboratory? It is of greater reliability and usefulness than the red cell count 169 Hematology that is performed manually. Microhematocrit method Materials required • Capillary tubes These need to be plain or heparinized capillaries, measuring 75mm in length with an internal diameter of 1mm and wall thickness of 0. The plain ones are used for 171 Hematology anticoagulated venous blood while the heparinized ones (inside coated with 2 I. Test method 1 Allow the blood to enter the tube by capillarity (if anticoagulated venous blood, adequate mixing is 173 Hematology mandatory) leaving at least 15mm unfilled (or fill 3/4th of the capillary tube). Since it is difficult to measure the volume of plasma trapped between the packed red cells (‘trapped plasma’), it is not customary in routine practice to correct for this trapped plasma. It is increased in hypochromic anemia, macrocytic anemia, sickle cell anemia, spherocytosis and thalassemia. Advantages of the Microhematocrit Method • It enables higher centrifugation speeds with consequent shorter centrifugation times and superior packing. A note should be made on the patient’s report if an abnormal plasma or buffy coat is seen as this is often an important clue for the clinician. When it contains an increased amount of bilirubin (as occurs in hemolytic anemia) it will appear abnormally yellow. When white cell numbers are significantly increased, this will be reflected in an increase in the volume of buffy coat layer. The method uses a Wintrobe tube which can also be used to determine the erythrocyte sedimentation test. One side is graduated from 0 to 10cm (0-100mm) from the bottom to the top, while the other side is graduated from 10 to 0cm (100-0mm) from bottom to top. The hematocrit is read from the scale on the right hand side of the tube taking the top of the black band of reduced erythrocytes immediately beneath the reddish gray leucocyte layer. District laboratories should check the reference ranges with their nearest Hematology 178 Hematology Reference Laboratory. These formulas were worked out and first applied to the classification of anemias by Maxwell Wintrobe in 1934. Abnormal 182 Hematology hemoglobins, such as in sickle cell anemia, can change the shape of red blood cells as well as cause them to hemolyze. Cells of normal size are called normocytic, smaller cells are microcytic, and larger cells are macrocytic. Cells with a normal concentration of hemoglobin are called normochromic; cells with a lower than normal concentration are called hypochromic. Because there is a physical limit to the amount of hemoglobin that can fit in a cell, there is no hyperchromic category. When examined under a microscope, normal red blood cells that contain a normal amount of hemoglobin stain pinkish red with a paler area in the center. It is a measurement of the degree of anisocytosis present, or the degree of red cell size variability in a blood sample. Moderate elevations are common in active inflammatory disease such as rheumatoid arthritis, chronic infections, collagen disease, and neoplastic disease. An initial period of a few minutes (approximately 10 minutes) during which rouleaux formation takes place 2. A period of approximately 40 minutes during which settling or sedimentation occurs at a more or less constant rate. A slower rate of fall (last 10 minutes) during which 192 Hematology packing of the sedimented red cell column occurs. Venous blood is diluted accurately in the proportion of one volume of citrate to four volumes of blood. The tube is placed in a strictly vertical position in the Westergren stand under room temperature conditions not exposed to direct sunlight and away from vibrations and draughts. After 1 hour read to the nearest 1mm the height of the clear plasma above the upper limit of the column of sedimenting red cells. A poor delineation of the upper layer of red cells, the so-called ‘stratified sedimentation’, has been attributed to the presence of many reticulocytes. Advantages of the method It more reliably reflects the clinical state and is the most sensitive method for serial study of chronic diseases, e. Disadvantages of the method 194 Hematology It requires a large amount of blood and involves dilution which may be one source of error. Interpretation of results Reference value Men: 0-15mm/hr; Women: 0-20mm/hr There is a progressive increase with age because of the decline in plasma albumin concentration. Enough blood to fill the Wintrobe tube (approximately 1ml) is drawn into a Pasteur pipette having a long stem. The Wintrobe tube is then filled from the bottom up 195 Hematology (so as to exclude any air bubbles) to the "0" mark.

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Difficulties in communication are among the most frequently reported problems of cancer patients (Wright et al 2002) generic solian 50 mg amex. Patient satisfaction is higher when clinicians:  Smiled a lot  Used an expressive tone of voice  Increased eye contact and face  Leaned forward  Gestured (Griffith et al 2003) Listening It is important to actively listen to the patient buy cheap solian 100mg line. The important behavioural aspects of effective listening are: S-O-L-E-R  Sit squarely in relation to the patient  Maintain an Open position  Lean slightly towards the client  Maintain Eye contact with the patient  Relax around the patient (Egan 1990) Barriers to effective listening:  Temptation to tell them what to do discount solian 50 mg, as opposed to letting them share their feelings  Not enough time to listen buy solian 50mg on line, share feelings, experiences  A feeling of vulnerability and fear of what the patient may ask (Donoghue and Siegel 2005) Responding to difficult emotions 1) Acute emotional distress Acute stress disorder is present in almost one third of patients after diagnosis (Kangas et al 2007). A distressed patient may be one who is demanding, unable to make decisions or angry (Bylund et al 2006; Knobf 2007). Patients exhibit a range of emotions post diagnosis including, mood changes such as:  Worry  Concerns with body image  Sadness  Sexuality  Anger  Employment  Fear of recurrence  Relationship issues 119 Responses of the clinician to emotional distress  Listen; ask open ended questions and show care, compassion and interest. Clinicians meeting anger may feel threatened, become defensive or, indeed, angry in response. These reactions are generally considered unhelpful as they are likely to result in an escalation of the patients anger (Cunningham, 2004). Develop a shared understanding of the experience, and develop shared goals from this point. After being told their diagnosis, approximately 20% of patients deny they have cancer; 26% partially suppress awareness of implementing death and 8% demonstrate complete denial (Greer, 1992). Strategies and communication skills for clinicians  Exclude misunderstanding or inadequate information  Determine whether denial requires management  Explore emotional background to fears  Provide information tailored to the needs of the patient and clarify goals of care  Be aware of cultural and religious issues  Monitor the shifting sand of denial as the disease progresses  Aim to increase a person’s self esteem, dignity, moral and life meaning (Greer 1992; Watson et al 1984; Erbil et al 1996; Schofield et al 2003) Useful Link for communication skills in cancer care: http://pro. Other Programmes to Support Cancer Patients Travel2Care scheme This scheme helps patients who are suffering from genuine financial hardship with travel costs due to travelling to a cancer centre. Care to drive programme Care to Drive is a volunteer-led transport initiative in which the Irish Cancer Society recruits and trains volunteers to drive patients to and from their chemotherapy appointments. Tax relief can also be claimed back on travelling costs for insured cancer patients. Dengue Fever 1 Introduction Dengue has a wide spectrum of clinical presentations, often with unpredictable clinical evolution and outcome. Reported case fatality rates are approximately 1%, but in India, Indonesia and Myanmar, focal outbreaks away from the urban areas have reported case- fatality rates of 3-5%. To observe for the following Danger signs and report immediately for hospital admission • Bleeding: - red spots or patches on the skin - bleeding from nose or gums - vomiting blood - black-coloured stools - heavy menstruation/vaginal bleeding • Frequent vomiting • Severe abdominal pain • Drowsiness, mental confusion or seizures • Pale, cold or clammy hands and feet • Difficulty in breathing Out -patient laboratory monitoring- as indicated • Haematocrit • White cell count • Platelet count 5. If not tolerated, start intravenous isotonic fluid therapy with or without dextrose at maintenance. If the haematocrit remains the same, continue with the same rate for another 2–4 hours and reassess. If the vital signs/haematocrit is worsening increase the fluid rate and refer immediately. Start with 5–7 ml/kg/hour for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or less according to the clinical response. If the haematocrit remains the same or rises only minimally, continue with the same rate (2–3 ml/kg/hr) for another 2–4 hours. If the vital signs are worsening and haematocrit is rising rapidly, increase the rate to 5–10 ml/kg/hour for 1–2 hours. Reassess the clinical status, repeat the haematocrit and review fluid infusion rates accordingly. Reduce intravenous fluids gradually when the rate of plasma leakage decreases towards the end of the critical phase. This is indicated by urine output and/or oral fluid intake that is/are adequate, or haematocrit decreasing below the baseline value in a stable patient. Parameters that should be monitored include hourly vital signs and peripheral perfusion. Internal bleeding is difficult to recognize in the presence of haemo-concentration. First correct the component of shock according to standard guidelines with early use of packed cell transfusion. Further infusion of large volumes of intravenous fluids will lead only to a poor outcome. If the patient remains in shock and the haematocrit is elevated, repeated small boluses of a colloid solution may help. Secondly, dextrose is rapidly metabolized resulting in a hypotonic solution that is inappropriate for shock correction. Consider in severe shock  Aim for ≈ 20% fall in haematocrit and adjust fluid rate downwards to avoid overload  Aim for minimal acceptable urine output (0. Flow Chart 1-Volume replacement flow chart for a patient with Severe (1) Dengue and a >20% increase in haematocrit. It results into significant morbidity ; affects precious growing period of a child, parental working days & possible negligence of other family members & also incurs formidable burden on scarce resources if treated improperly or inadequately. However, with the widespread availability of radioimaging techniques , fibrinolytic agents, safe & effective surgical procedures ( open or thoracoscopy ) the recent data is leading to more focused management guidelines though optimal management is still controversial (22). It could be localised or free collection of purulent material in pleural space as a result of combination of inoculation of bacteria & culture medium of pleural fluid. Stage 2 or Fibrinopurulent or Transitional phase ( 3 to 21 days ): There is deposition of fibrin in the pleural space leading to septations & formation of loculations. The presence of septations (fibrinous strands 17 in pleural fluid )doesn’t necessarily mean fluid doesn’t flow freely, although separate loculations will not communicate with each other. These solid fibrous or leather like peels may prevent lung re- expansion ( “trapped lung” ), impair lung function & create a persistent pleural space with potential for infection. It achieves debridement of fibrinous pyogenic material, breakdown of loculations, and drainage of pus from the pleural cavity under direct vision. Decortication involves an open posterolateral thoracotomy and excision of the thick fibrous pleural rind with evacuation of pyogenic material. It is a longer and more complicated procedure leaving a larger linear scar along the rib line. The reported rate of empyema thoracis complicating community acquired pneumonia is said to be 27% in children(21). The prevalence of small parapneumonic effusions is difficult to estimate (and often undetected )& they are unlikely to be reported in case series. Since Staph aureus is the most common organism responsible in our country improving hygienic conditions especially during hot & humid conditions of the year ie April to August will bring down in general incidence & severity of staph infections. Improvement in dental/oral hygiene as it is a welknown predisposing factor for development of aspiration pneumonia. Pediatric surgeon or General surgeon familiar with basic thoracic surgery along with paediatrician or respiratory physician should manage these cases. They should be monitored closely & carefully by frequent clinical assessment & room air saturation by pulse oximeter whenever child is in resp. Diagnostic imaging, microbiology, pleural fluid analysis should be carried out promptly. Conservative management to be started swiftly & supported by antipyretics, analgesia, oxygen , if necessary. Antibiotics : Intravenous antibiotics for 10 to 14 days for community acquired pneumonia covering Gram positive cocci & anaerobes to be started empirically pending preferably c & s report. Broad spectrum coverage should be started for hospital acquired pneumonia as well as empyema following surgery, trauma & aspiration.

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The shape of epithelial cells may be squamous 100 mg solian with visa, cuboidal order solian 50 mg free shipping, or columnar generic solian 50mg online; intermediate forms are often encountered buy solian 100mg without a prescription. Stratified epithelia are classified according to the shape of the cells at the free surface and can be squamous, cuboidal, columnar, or transitional. Transitional epithelia line cavities in the urinary tract, which may be distended, and the thickness of the epithelium varies with the degree of distention. Beneath the layer of epithelial cells is an underlying non-cellular structure known as the basal lamina, which is secreted by the epithelial cells. Together the basal lamina and the underlying layer make up the basement membrane, which can usually be seen with light microscopy. Find the basement membrane and lumen of the tubules to help you determine the basal and apical membranes, respectively. This is because they are highly interdigitated, a configuration that increases the surface area for transport across the cell membranes. Be sure you locate regions where the epithelium is cut longitudinally to observe the simple columnar epithelium. In tangential sections portions of cells in various planes of section may give the impression that the epithelium is stratified. In longitudinally sectioned cells, the junctional complex is seen as a dark dot of silver deposit at the apical lateral borders of the cells. In regions where the epithelium has been cut in cross or oblique section, the junctional complex has a belt-like appearance and can be seen to encircle the cells (hexagonal Junctional complex in cross-section shape). In addition the Bodian silver stains secretory granules within enteroendocrine cells in the epithelium and the basal lamina. In fact all of the cells rest on the basal lamina, but not all of the cells have apices that reach the lumen. The cells that are confined to the base are stem cells that are the sources of the cells whose apices do reach the lumen. Stratified squamous keratinized epithelium #4 Skin, H&E The epithelium of the skin is known as the epidermis. The stratified squamous epithelium lining the esophagus is non-keratinized in humans, but keratinized in some other species. Consult electron micrographs to understand the morphological changes that accompany expansion and contraction of the lumen. Connective tissue is comprised of cells, formed fibers, and amorphous extracellular matrix (ground substance). Both the fibers and ground substance are secreted by the connective tissue cells that are interspersed and embedded in the matrix. Functions of the connective tissue include support and binding together of the other tissues; providing a medium for the passage of metabolites; serving as a storage site for lipids, water and electrolytes; aiding in protection against infection by an inflammatory reaction mediated by cells that have migrated into the connective tissue from the blood; and repair by the formation of scar tissue. Mesenchyme is derived primarily from the mesodermal germ layer of the developing embryo, but the ectodermal neural crest is known to give rise to some mesenchymal cells (ecto- mesenchyme). Reticular connective tissue - forms a supporting framework for spleen, lymph nodes, bone marrow, liver, glands, and striated muscle fibers. Adipose connective tissue - a modification of reticular connective tissue, characterized by an extensive intracellular accumulation of lipid droplets. Elastic - elastic ligaments (ligamentum nuchae flavate and interspinous ligaments), true vocal cords E. Mesenchyme (Embryonic Connective Tissue) Primitive connective tissue that contains precursors for connective tissue, as well as other tissue types. The large number of cells frequently makes it difficult to distinguish the fibrous component without the use of special stains. The fibers in the matrix have a loose and irregular arrangement, and they consist of collagenous, elastic, or reticular fibers. Fibroblasts and macrophages are the most common cells in loose connective tissue, but mast cells, plasma cells, neutrophils and fat cells may also be found. Examine the scanned image at low power, and note that one surface is indented by pits that are lined by columnar epithelial cells. The lymphocytes, which are located within the interstices of this framework, are not well seen in this slide. At higher magnification observe that the intracytoplasmic lipid has been extracted from the fat cells during the histological preparation of the tissue. The thin peripheral ring of cytoplasm and the flattened peripheral nucleus, coupled with the large central vacuole results in the "signet ring" appearance of fat cells. At higher magnification observe the white fat in which each cell contains a single fat droplet (unilocular). Its thick collagenous (type I) bundles stain intensely with eosin and can be seen to course in various directions. Immediately surrounding the lining cells is a very small zone of pale-staining loose areolar connective tissue. Compare the appearance of the collagen bundles (Type I collagen) and fibroblasts with that of the skeletal muscle fibers on the same section. Tendon top, skeletal muscle bottom #11 Bone, rib (H&E) Find the regions of the dense fibrous regularly arranged connective tissue (tendon). Elastic fibers stain reddish-brown to black and form prominent fenestrated, elastic sheets in the aorta. As in other connective tissues, its matrix is composed of fibers (collagenous or elastic) and a ground substance that is rich in extracellular glycosaminoglycans (particularly the chondroitin sulfates). Cartilage is the primary skeletal tissue of the fetus, and it serves as a model for the development of endochondral bone. In the adult, cartilage forms the articular surfaces of joints, the skeleton of the external ear, the septum of the nose, supporting rings and plates of the trachea and bronchi, and intervertebral discs. At higher magnification observe that a perichondrium surrounds the cartilage; this merges with the cartilage on one side and with the surrounding connective tissue of the other side. This is due to the From top to bottom: masking of the collagen fibers by the high concentration of cartilage, pericardium, the glycosaminoglycans in the ground substance. The general organization of this type of cartilage is similar to that of hyaline cartilage, except that elastic fibers predominate over collagen fibers in the matrix. The deposition of inorganic calcium phosphate salts as hydroxyapatite crystals within its matrix is a distinguishing characteristic of bone. In addition, bone functions as a homeostatic reservoir of calcium and phosphate ions and it encloses the hematopoietic elements of the bone marrow. Spongy bone consists of a lattice of branching bony spicules, known as trabeculae, which are surrounded by bone marrow in some regions. Immature (woven) bone (see below in "bone development") is the first bone laid down in prenatal life or in the repair of bone fractures. In this type of bone, the matrix immediately surrounding the osteoblast is called osteoid and is not mineralized. Immature bone is characterized by irregularly arranged, interwoven collagenous fibers within a matrix containing proteoglycans. There are two basic techniques for studying bone with the light microscope, and both of these types of preparations must be studied to appreciate the organic and inorganic components of bone.

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