E. Arakos. Gettysburg College.
Damage extent and predictors in adult and juvenile dermatomyositis and polymyositis as determined with the myositis damage index buy kamagra soft 100 mg visa male erectile dysfunction statistics. Muscle enzymes • Serum levels of enzymes released from damaged muscle are helpful in the diagnosis and monitoring of the disease kamagra soft 100 mg without prescription erectile dysfunction treatment kerala. It is released from regenerating skeletal muscle fibres and also damaged myocardiocytes buy generic kamagra soft 100 mg online erectile dysfunction doctors in nj. Therefore the site of biopsy should be preferably from a symptomatic muscle which is not atrophic. Characteristic findings are intracellular amyloid deposits or basophilic intracellular vacuoles (‘inclusion bodies’) seen on electron microscopy. It is worth noting up-to-date publications in this area given that antibody immunological tests through specialist labs can help in difficult cases where malignancy and drugs are being considered as causes. The latter features are in contrast to neuropathies where there is decreased recruitment and interference. Treatment Treatment should be started promptly pending completion of investigations, particularly in acute-onset weakness, dysphagia, respiratory insufficiency, and systemic complications. Exercise should be used with caution during periods of disease activity, but there is no evidence that it causes prolonged worsening in muscle enzyme levels or inflammation. This may confer a risk factor for developing adult myositis, suggesting vitamin D replacement therapy is important. If treatment is withheld due to an absence of myositis, the patient should be followed closely, especially in the first 2 years after onset to avoid delay in treatment should myositis develop. One retrospective study estimated a mortality rate of 22%, mostly due to malignancy and pulmonary disease. Some clinical benefits seen with reduced enzyme levels in each case Anakinra 12-month open label trial. Anakinra treatment in patients with refractory inflammatory myopathies and possible predictive response biomarkers: a mechanistic study with 12 months follow- up. If there is continued decline in strength or function, immunosuppression should be discontinued. Patients may need assistance with daily activities within 10 years and some may be wheelchair bound within 15 years from onset of symptoms. Differential diagnosis of muscle weakness in childhood Muscle weakness may be a sign of muscle disease or a manifestation of a muscle function-related pathology or even general pathology. Juvenile polymyositis • Is very rare and results in more clinically apparent proximal and distal muscle weakness with little skin involvement. Consensus treatments for moderate juvenile dermatomyositis: beyond the first two months. Results of the second Childhood Arthritis and Rheumatology Research Alliance consensus conference. Patients with ‘large vessel vasculitis’ and ‘small vessel vasculitis’ can have disease that affects some medium-sized vessels. However, this is a useful framework for the clinician, since categorizing the patient into one of these groups can narrow the differential diagnosis considerably. Single-organ vasculitis • Cutaneous leucocytoclastic angiitis • Cutaneous arteritis • Primary central nervous system vasculitis • Isolated aortitis • Others. Vasculitis associated with systemic diseases • Lupus vasculitis • Rheumatoid vasculitis • Sarcoid vasculitis • Others. General principles of vasculitis management • To be complete, any evaluation of a chronic disease (such as primary systemic vasculitis) must include both an assessment of disease activity and of disease damage. The concept of damage denotes the aspects of disease that are unlikely to reverse with immunosuppression (such as pulmonary fibrosis or renal insufficiency). This index provides another useful method of classifying patients with vasculitis. Large vessel vasculitis • The ‘large vessels’ include the aorta and its main branches (i. Subclavian involvement causes arm claudication and diminished pulses on examination. The pulmonary arteries can also be involved, although this is relatively uncommon. Presentation • Systemic symptoms are common in the early phase of the disease, including fever, malaise, weight loss, and fatigue. The majority of patients (75%) will have some impairment of daily living, and 50% are permanently disabled. The main complications are exacerbation of hypertension and congestive cardiac failure. The anaesthetist should be made aware of the diagnosis, as the patient may require invasive blood pressure monitoring during delivery. Shoulder and pelvic girdle pain which is primarily muscular in the absence of true muscle weakness. Presentation • Severe headache and scalp tenderness localized to the occiput or temporal area are common initial symptoms, and are present in 70% of cases. Patients may describe symptoms of amaurosis fugax by temporary ‘curtaining’ of the visual field. A history of prior transient visual loss is the strongest predictor for subsequent permanent visual loss. Biopsies may be helpful to confirm the diagnosis up to 2 weeks after steroids are started. Various abnormalities described include stenosis, occlusion and the presence of a hypoechoic ‘halo’ (halo sign) around the temporal arteries. The American College of Rheumatology 1990 criteria for the classification of the giant cell arteritis. Non-specific abdominal pain, gut/gallbladder infarction, and pancreatitis are all features. Nasal or oral inflammation: development of painful or painless oral ulcers or purulent or bloody nasal discharge. Abnormal chest radiograph: the chest radiograph may show nodules, cavities, or infiltrate. Ear, nose, and throat symptoms • Up to 90% of patients have ear, nose, and throat involvement. Subglottic stenosis may worsen even when a patient is otherwise in remission, and responds better to steroid injections than systemic therapy. Multiple nodules with or without cavitation are found in the lungs of asymptomatic patients. Eye disease • Granulomatous lesions may obstruct the nasolacrimal duct and cause orbital pseudotumour, with optic nerve compression from masses developing in the retrobulbar space. Bronchoscopy with bronchoalveolar lavage will demonstrate haemosiderin-laden macrophages. Many of these patients will have been treated with a leukotriene inhibitor (although leukotriene inhibitors do not cause the disease). Other treatments • Plasma exchange has been used with some effect in those with severe renal disease, although the benefit is transient. Modern immunosuppressive regimens have transformed these diseases into chronic conditions, characterized by cycles of relapse and remission.
Retractors for Transoral Robotic 6 Surgery Emily Funk order kamagra soft 100 mg fast delivery erectile dysfunction pills herbal, Aaron Baker discount 100mg kamagra soft visa erectile dysfunction pump operation, David Goldenberg buy kamagra soft no prescription impotence uk, and Neerav Goyal 6. Factors in choosing a and neck, larger surgical approaches such as a retractor system include freedom of motion, lip-split mandibulotomy, lateral pharyngotomy, accommodation of endotracheal tube, and safe or transhyoid approach can be avoided for oro- oral retraction methods to avoid ischemic or trau- pharyngeal and laryngeal lesions. The ultimate goal of novel retrac- made signifcant advances over the past 10+ tion methods is to produce a mechanism by years and is a viable option in the surgical treat- which the operator has an adequate feld of view ment of benign and malignant lesions of these of the surgical site, while also accommodating an sites. However, to be a viable alternative to open endoscopic camera and robotic effector arms. Samuel Crowe, while in training under Harvey Cushing at the Johns Hopkins Hospital, in conjunction with Dr. The Crowe-Davis gag tongue, although some base of tongue lesions relies on the patient having stable and intact ante- may be accessible . The open-sided design of rior dentition for the superior portion of the the Crowe-Davis retractor does, ostensibly, allow retractor to seat. In the 1940s, Robert McIvor, for an increased lateral range of motion com- seeing the pitfalls of the gags available at the pared to the McIvor, without collision with the time, designed the McIvor atraumatic gag, using retractor. This retractor is also useful in the edentulous sure of the base of tongue; however, it is limited patient by placing the “point” of the retractor in in its fexibility for these procedures, as there are the arch of the palate, providing stable retraction few options for the tongue retraction blade and on the maxillary alveolus. Similar to the Crowe-Davis and McIvor, exposure of the oropharynx is excellent, In the 1960s, Dingman and Grabb  at the although the closed frame restricts the motion of University of Michigan described a new, closed- the robotic arms and camera. This limitation fur- frame retractor system to allow for improved ther increases as the surgeon moves to the base of visualization of the oral cavity and oropharynx. There are few tongue retractor options with retraction blade but also attachments to the lat- these systems, limiting the ability to obtain direct eral portion of the frame allowing for retraction exposure of the base of tongue. In addition retraction has made it a staple in surgery on the to the tongue and cheek retractors, retraction palate, primarily cleft surgery . Thus, it was chosen for use in the laryngeal, hypopharyngeal, and base of tongue human base of tongue resections. The retractor features a closed rect- geal blade ft into the vallecula and provided angular frame, cheek retractors, tongue blades, visualization of the junction of the base of tongue laryngeal blades, and a vallecular blade . Some of these blades of tongue, eliminating the requirement of also offer the unique feature of “cutout” compo- mandibulotomy with a lip-split or transpharyn- nents designed for use in conjunction with the geal approaches that carry high risk of damage to angle and depth adjustments to provide improved delicate structures, with effects on mastication, exposure of more distal operative sites (Fig. In tumors as it is capable of exposing the larynx, a comparison to the Dingman and Crowe-Davis weakness of the Dingman and Crowe-Davis. The two small articulating clamps of the glottic and glottic lesions in 2009 . These modifcations included widening of the aperture at the frame to iv allow for more room for instruments and the camera, as well as new blades for exposure of the supraglottis (Fig. The threaded adjustment system of this The retractor features a rounded frame with retractor provides the ability to slide the vertical blades that allow adjustment of both insertion blades upward and downward, as well as backward depth and insertion angle, cheek retractors, and forward. The for procedures in the oral cavity, oropharynx, hypo- curved frame adapts to the shape of the patient’s pharynx, larynx, and upper esophagus. There is also a ratchet system that two with oropharyngeal tumors, one with a supra- is built into the frame to assist with vertical sus- glottic tumor, one with hypertrophy of the palatine pension of the device, a feature of standard laryn- tonsils, and one with a parapharyngeal space goscopes that is not available in other retractor schwannoma. Recent advancements have led to the pharyngeal, and supraglottic procedures development of a smaller, fexible surgical robot (unpublished report/personal communication). These adjustments, along with the variety use with this robot, featuring interchangeable of blades available, make the system useful in all tongue retractors. This frame allows for attachment of use of the Flex robot and retractor system in cheek retractors similar to the Dingman retractor, human patients. They found that the surgical with a frame size that increases the range of exposure was excellent in all cases of motion of the instruments (Fig. In addition, oropharyngeal, base of tongue, and hypopharyn- the system includes a suction attachment to clear geal surgery. The However, effciently and safely using these current size of robotic endoscope and instrument systems does require adequate exposure of the arms can be diffcult to introduce into the pediatric surgical site. In children, exposure can be particu- surgeon must be familiar with the many retrac- larly challenging, and specifcally designed mouth tor systems available to choose the ideal retractors for infants and small children are cur- retractor. While the frame size is constant A plethora of retractors have been developed in available systems, some blades can be used for to allow for adequate access without hindering pediatric applications, particularly in procedures of visualization of lesions of the oropharynx, the oropharynx. The Crowe-Davis, McIvor, and hypopharynx, and larynx (the reviewed retrac- Dingman mouth gags offer tongue blades that are tors are summarized in Table 6. Transoral robotic surgery: does the ends justify the sillar and nasopharyngeal infections to general sys- means? Transoral robotic surgery: radical tonsillec- Surg Off J Am Acad Otolaryngol Head Neck Surg. Robotic gag for better visibility and access in the management surgery in the pediatric airway: application and safety. Robot-assisted pharyngeal and laryngeal microsur- robotic-assisted laryngeal cleft repair in the pediatric gery: results of robotic cadaver dissections. Transoral Robotic Surgery 7 for Tonsillar Cancer Shivani Shah-Becker, Robert Saadi, and David Goldenberg 7. The magnifed three-dimensional view along with Surgery for tonsillar cancer has previously been the use of angled endoscopic cameras with 360° limited to early-stage and intra-tonsillar tumors radius provides visualization beyond the tonsil- due to inadequate visualization of the oropharynx lar fossa to the great vessels laterally, the pal- via transoral approaches. Open approaches to the ate and nasopharynx superiorly, and the tongue oropharynx are often quite morbid, requiring base inferiorly, which could not be achieved mandibulotomy or partial mandibulectomy and using traditional transoral headlight or operative tracheotomy in order to achieve oncologic resec- microscope alone. Until recently, trends have been to treat oropha- ryngeal carcinomas with primary radiation ther- 7. However, radiation therapy is also not for Tonsillar Cancer without signifcant toxicity and side effects, including xerostomia, dental complications, and A renewed interest in a surgical approach to oro- long-term dysphagia requiring a feeding tube . The transoral approach, a in tonsillar cancer has allowed more advanced minimally invasive technique taking advantage and extensive tumors to be treated with surgery. The poor visualization and reliance on rigid instruments made the approach unfavorable for resection deep within the oropharynx. A fexible robot the challenges with manipulating the tumor to was developed for minimally invasive surgery provide more deliberate dissection and complete applications at Carnegie Mellon University. The The introduction of the “robot” has reduced fexible robot was further customized and trans- some of these challenges, and its use in carefully formed into the Medrobotics Flex System, devel- selected tongue base, tonsillar, and certain laryn- oped specifcally for use in surgical applications geal and hypopharyngeal cases has shown great requiring nonlinear maneuverability such as tran- success. Their exclusion criteria were limited to unresect- able neck nodes, mandibular invasion, involve- ment of >50% of the tongue base, involvement of >50% of the posterior pharyngeal wall, carotid artery involvement, or fxation to prevertebral fascia. Twenty-fve of the 27 tumors were resected with negative margins, and there were no local or regional recurrences. Two patients required a tracheotomy, and only one experi- enced persistent diffculty swallowing . The similar to that in other transoral robotic head and patients who are the best candidates typically neck surgery cases. The robot base is on the have early-stage (T1 to T2) tumors and have the patient’s left and the scrub nurse on the patient’s potential to avoid chemoradiation therapy. A bedside assistant is seated at the head of who have advanced-stage (T3 or T4) tumors will the patient. Exposure to the oropharynx is typi- However, in the case of low-volume T3 disease, cally achieved using either a Crowe-Davis or undergoing robotic surgery may still allow the Dingman mouth gag.
Meanwhile your friend order kamagra soft with amex erectile dysfunction at age 26, who is travelling with you purchase generic kamagra soft on-line erectile dysfunction among young adults, visits a different prac- titioner and is given the new vaccine discount kamagra soft 100mg overnight delivery coke causes erectile dysfunction. You experience some unpleasant side effects and when you read up about the vaccine, you discover that your friend is better protected than you are against the disease in question – and did not experience any side effects! You feel angry and your trust in the practitioner who had not given you the most up-to-date and best available healthcare is broken. If you did make a complaint, the practitioner would then have to justify why this out-of-date vaccine was given. This would be diffcult to do if all the evi- dence pointed towards the newer vaccine. As a health or social care practitioner, you are accountable to your manager or university (if you are a student), your professional organization and to the law. This means that you must be able to justify and give a clear account of and rationale for your practice. If there was a standard or policy document in his or her place of work that rec- ommended the newer vaccine, then the practitioner would fnd it diffcult to justify administering the old vaccine. Even if no such documentation existed, the practitioner would still fnd it diffcult to justify why an outdated vaccine was administered when a more effective vaccine with fewer side effects was available. We can see that when you are called to account for your practice, you will only be able to do so if you have administered care that is based on the best available evidence. Find out what your professional body, college or association says about your accountability and evidence-based practice. They publish their Stan- dards of Conduct, Performance and Ethics (2012) (available at: http://www. They publish The Code, their Standards of Conduct, Performance and Ethics (2008) (available at http://www. The Code declares that nurses and midwives are accountable for the care they deliver. Therefore, if you are called upon to account for your practice, you must be able to provide a sound rationale for why you acted as you did. If you are only able to say ‘I was told to do this’ or ‘I’ve always done it this way’, your practice will look very poor indeed! Students are expected to work towards these stan- dards in order to obtain registration and failure to do so may affect progres- sion towards qualifcation. Individual colleges or associations may also be involved in setting profes- sional guidance and you should access their websites to see what relates to your own profession. Do you think the practitioner referred to earlier would be found guilty of pro- fessional misconduct because of the decision to administer a vaccine which had been superseded by a more effective vaccine? Would that verdict have been reached if he/she had used an evidence-based approach to the selection of the appropriate vaccine? Whilst the mechanisms of clinical governance are liable to change, the concept of clinical governance is that of accountability of the individual practitioner to the institution in which he or she is employed (http://www. The purpose of clinical governance is to ensure that the institution – in addi- tion to the individual practitioner – is accountable for the care that its service provides. The Kings Fund offers a directory of the monitoring and quality organiza- tions including the Quality Care Commission (http://www. Part of this governance is ensuring staff are educated and trained and that they are using up-to-date interventions. In addition, the Essence of Care benchmarking statements have been designed to contribute to the introduction of clinical governance at local level. Being able to jus- tify the care that you give may protect you or your organization from a claim in negligence. There is a developing culture of litigation and claims against health and social care organizations. Patients or clients who are unhappy about the care they receive can make a claim in negligence if they have suffered harm as a result of that care. Clinical governance, discussed earlier, includes several measures to ensure we provide safe and effective care. Let’s return to the example about the administration of an outdated travel vaccination. Let’s say that the worst does happen and you contract a serious tropical disease whilst you are away, the disease against which you had been vaccinated (with the less effective vaccine). In order to seek compensation you make a claim of negligence against the healthcare provider who did not use the best available evidence when selecting your travel vaccinations. To make a successful claim in negligence against a health and social care pro- vider, the patient/client has to demonstrate that the healthcare provider failed in their duty to provide care and that this failure led to harm. The courts have consistently ruled that such a failure occurs if the health or social care provider has provided care that is not evidence based. In this case, the administration of an outdated vaccine that is less effective than its newer version led to a greater likelihood of your contracting the disease and might lead to a claim of negli- gence. Under the current system, you can only make a claim in negligence if you have suffered harm. Therefore, you would not be able to claim in negligence just because you had received the less effective vaccine; you would only be able to make a claim if you did contract the disease or suffered some other harm. Let’s then say that unfortunately your friend also contracts the disease, despite receiving the newer vaccine – (no vaccination is ever 100 per cent effec- tive). If (s)he then attempts to bring a case in negligence against the health and social care provider, (s)he is less likely to be able to succeed because the practitioner in this case used the most up-to-date evidence to select the appro- priate vaccine and hence did not fail in the duty owed to the patient/client. Being able to provide a good rationale or explanation for your practice is an essential component of the concept ‘evidence-based practice’ and might even prevent you from becoming involved in any legal proceedings. Therefore, you can see that you are less likely to make errors or give the wrong information to your service users if you follow recommendations for best practice and have a sound rationale for what you do. We have used examples from professional health and social care practice to illustrate this and the likely implications that can arise from following a ‘non evidence-based’ approach. Throughout this book, we will look in more detail at how you might achieve an evidence-based approach. You wonder why this is and when you ask ques- tions in your professional practice, you get different answers! For both of the examples above you would need to take an evidence-based approach and ask the question: ‘What is the evidence for the way the care was undertaken? You might fnd a wide range of different research stud- ies, case studies, guidelines, literature reviews or opinion articles. You would then need to judge the quality of the evidence you fnd and whether it is relevant to your problem or issue. You would probably consider any research that you fnd to be of more value than someone’s personal view.
If blood is left myeloproliferative neoplasms buy kamagra soft with visa impotence male, and following the admin at room temperature for a long time order cheapest kamagra soft erectile dysfunction bph, a similar change istration of cytotoxic drugs and antimetabolites order kamagra soft canada impotence postage stamp test. Leucocytes that have macropolycytes have nuclear and cytoplasmic staining degenerated to the extent that nuclear material is no characteristics that are the same as those of other neu longer apparent have been designated necrotic; this is trophils, but in megaloblastic anaemia macropolycytes generally an artefact consequent on prolonged storage. The chromatin has con densed and the nucleus has fragmented into rounded pyknotic masses. Occasionally, it is observed Neutrophil aggregation in a patient over many months or years and may then be Aggregation of neutrophils with or without aggregation of associated with autoimmune disease (Fig. Fragmentation of neutrophils has been observed, in association with microangiopathic haemolytic anaemia, is usually bilobed but occasional nuclei are trilobed, in a patient with clot formation at the tip of a dialysis the average lobe count being about 2. Neoplastic cells, the frequency of drumsticks is related to the degree of such as leukaemic blast cells, are more prone to frag lobulation of the nucleus they are quite infrequent. The cytoplasm of the eosinophil eosinophils is weakly basophilic, ribosomes and rough The eosinophil (Fig. It can also be a hereditary phenomenon ; in one family hyper segmented eosinophils were also poorly granulated  without any apparent clinical defect. Increased lobulation has also been reported, together with decreased numbers of eosinophils, in Down syn drome [156,250]. Hypersegmentation, hyposegmentation and ring‐ shaped nuclei can all occur as acquired abnormali ties. Hyposegmentation of eosinophil nuclei occurs as an acquired phenomenon in myeloproliferative neoplasms, including primary myelofbrosis, and in Fig. Both eosinophils have nuclei chromatin may be clumped and the nuclei entirely with four lobes. Very occasional may have both hypersegmented and hyposegmented eosinophils in healthy subjects contain some granules eosinophils. Ring eosinophils are seen in a variety of conditions ; they appear to Abnormalities of eosinophil nuclei have no specifc diagnostic signifcance. Howell–Jolly Eosinophils may show nuclear hypersegmenta body‐like inclusions, likely to be drug induced, have tion (Fig. Morphology of blood cells 121 anomaly, eosinophil granules may be grey‐green or purple on Romanowsky staining . Abnormalities of eosinophil granules and cytoplasm Abnormal eosinophil granules may be seen, together with abnormal neutrophil granules, in a variety of Fig. Cytoplasmic inclusions are However, the changes are quite non‐specifc, being also present in eosinophils in the May–Hegglin anomaly sometimes seen in reactive eosinophilia. For example,  and in the actin inclusion (Brandalise) syn among seven patients with eosinophilia associated with drome . B and T lymphoblastic leukaemia or lymphoma fve had In acquired disorders of granulopoiesis it is not cytologically abnormal eosinophils . These the basophil are immature granules, sometimes designated ‘pro‐ The basophil (Fig. Basophil nuclei may be non‐lobu larly cases of acute myelomonocytic leukaemia with lated in the Pelger–Huët anomaly (Fig 3. Basophils eosinophilia associated with inversion of chromo have abnormal granules in various inherited conditions some 16. In acquired disorders, eosinophils may be vacuolated or wholly or partly agranular. Hypogranularity could result from defective formation of eosinophil granules in dysmyelopoietic states, but since it is usually accom panied by vacuolation it appears likely that in most instances it results from degranulation. Morphology of blood cells 123 Lymphocytes and plasma cells the lymphocyte Peripheral blood lymphocytes vary in diameter from 10 to 16 μm. The smaller lymphocytes (10–12 μm), which predominate, usually have scanty cytoplasm and a round or slightly indented nucleus with condensed chromatin (Fig. The larger lymphocytes (12–16 μm), which usually constitute about 10% of circulating lymphocytes, have more abundant cytoplasm and the nuclear chroma tin is somewhat less condensed (Fig. The smaller lymphocytes are usually circular in outline, whereas larger ones may be somewhat irregular. A reduction in the number of gran ules can also be artefactual since basophil granules are highly water soluble. In healthy sub jects they sometimes constitute as many as 10–15% of lymphocytes, but usually they are less frequent. Occasionally, in the Alder–Reilly anomaly, inclusions Mature lymphocytes have a nucleolus but, because are found in lymphocytes in the absence of neutro of the condensation of the chromatin, it is not usually phil abnormalities. In large lymphocytes the found when the Alder–Reilly anomaly is consequent nucleolus can sometimes be discerned. Because of the on Tay–Sachs disease or on the mucopolysaccharidoses, chromatin condensation, it is similarly diffcult to detect although they are rare in Morquio syndrome. Heterozy sex chromatin in lymphocytes, but sometimes it is visible gous carriers for Tay–Sachs disease may have lympho condensed beneath the nuclear membrane in the larger cyte inclusions , but in a much lower proportion of lymphocytes with more dispersed chromatin . Alder–Reilly inclu lymphocytes of infants and children are larger and more sions may be round or comma‐shaped; they are some pleomorphic than those of adults. In general, the func times surrounded by a halo, and tend to be clustered tional subsets of lymphocytes cannot be distinguished at one pole of the cell (see Fig. When the morphologically, but lymphokine‐activated cytotoxic T Alder–Reilly anomaly is due to one of the mucopolysac cells and natural killer cells are found within the popu charidoses the inclusions stain polychromatically with lation of large granular lymphocytes. Inclusions may be found in lymphocytes in the Lymphocyte vacuolation occurs in many inherited Chédiak–Higashi syndrome and Alder–Reilly anomaly metabolic disorders including I‐cell disease (Fig. In the Chédiak–Higashi syndrome the sialidosis (mucolipidosis type I), the mucopolysacchari lymphocyte inclusions can be very large (Fig. Heterozygous carriers of the disease and larger vacuoles in infantile (type 1) disease) Chédiak–Higashi syndrome may also have lymphocyte (see Fig 3. In Tay–Sachs disease and Batten–Spielmeyer–Vogt immunological stimuli by an increase in number and disease, heterozygous carriers may also have lympho cytological alterations. Intermediate vacuolation varies: it may be lipid, glycogen or muco stages are also seen and are designated plasmacytoid polysaccharide. Morphology of blood cells 127 lymphocytes may contain abundant globular inclu sions (Fig. Such cells have been called ‘Mott cells’, ‘morular cells’ or ‘grape cells’ and the inclusions they contain are known as Russell bodies. Both T and B lymphocytes can also transform into immunoblasts – large cells with a central prominent nucleolus and abundant baso philic cytoplasm (Fig. Cells showing other less specifc changes in lymphocyte morphology are subsumed under the designation ‘atypical lympho cytes’ or ‘atypical mononuclear cells’ (Fig. Abnormalities include increased size of the cell, immaturity of the nucleus including lack of chroma Fig. Cleft lymphocytes can be seen in pertussis and respir atory syncytial virus infection. Abnormal nuclear lobulation can be phocytes are induced by natalizumab therapy . Howell–Jolly body‐ The number of large granular lymphocytes may also like inclusions, likely to be drug‐induced, have been increase as a reactive phenomenon, e.