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Transcutaneous electric nerve stimulation is considered safe for patients with bipolar pacemakers generic viagra super active 50mg on line erectile dysfunction freedom. Some types of dental equipment may cause pacemaker inhibition buy viagra super active 100 mg lowest price erectile dysfunction injection therapy video, particularly for unipolar pacemakers. Vibrations may increase the pacing rate of activity-sensing rate-adaptive pacemakers. Seizure activity during the procedure may produce myopotential inhibition of unipolar pacemakers. Diathermy may result in pacemaker interference or damage if applied to the region near the pulse generator. Older models were reported to interfere with cardiac pacemakers while transmitting or receiving calls. A pacemaker patient should not carry a cellular telephone near the pacemaker site (i. The field may result in pacemaker interference, primarily inhibition of pacemaker output. This includes devices, such as arc welders, that may generate strong electrical fields. The strength of the electrical field varies among various types of equipment and if sufficiently strong may interfere with unipolar pacemakers. Because of better sealing of microwave ovens and improved shielding of pulse generators, interference with pacemakers by microwave ovens is no longer considered a significant problem. Although the metal detectors in public places such as airports may raise an alarm because of detection of a pacemaker, there is generally no significant interference with pacemaker function. Patients should avoid lingering around these devices and pass through them at a normal speed. These areas may cause inhibition or asynchronous pacing in unipolar pacemakers if the patient is quite close to the electrical field. At usual public distances from such areas, there should be no pacemaker interference. The majority of pacemakers used today contain protective algorithms that make prolonged inhibition uncommon. This response is usually well tolerated, but in certain individuals when sustained it may cause palpitations, hypotension, or angina. Algorithms are based upon the principle that detected rapid frequency signals are unlikely to represent myocardial activation. The pacemaker is programmed to have a noise sampling window during the ventricular refractory period. In most devices, repetitive signaling detected in the noise sampling window reverts the device to asynchronous pacing. Also, pacing may rarely occur during the ventricular vulnerable period and may initiate ventricular arrhythmias. Numerous clinical trials, mostly small and nonrandomized, have been performed with regard to exercise capacity and quality of life for various pacemaker modes, chamber(s) paced, rate-adaptive pacing, and types of sensors. There are conflicting data regarding the benefit of dual-chamber pacing over rate-adaptive ventricular pacing. However, there are several randomized trials demonstrating that atrial-based pacing does, in fact, lead to a reduction in both atrial fibrillation and stroke. The following paragraphs summarize some of the larger-scale, randomized studies of ventricular- versus atrial-based cardiac pacing modes. A single-blind, randomized, controlled trial of ventricular pacing versus dual-chamber pacing in 407 patients older than 65 years. In this trial, 1,474 patients were assigned to ventricular pacing and 1,094 patients to physiologic pacing. However, the annual rate of atrial fibrillation was significantly lower in the atrial pacing group, although there was a 2-year delay before this beneficial effect emerged. There was a 50% reduction in perioperative complications with the implant of ventricular pacing systems, but in the ventricular pacing group, there was a 5% incidence of pacemaker syndrome that required upgrade to a dual- chamber device. A randomized trial that attempted to compare dual-chamber with single-chamber ventricular pacing in 2,010 patients with sinus node dysfunction. There was no advantage for dual-chamber pacing over single-chamber ventricular pacing in terms of the trial’s primary end point: Death from any cause or nonfatal stroke over 33. However, some advantages were seen with the dual-chamber modality in secondary end points, including reductions in atrial fibrillation and symptoms of heart failure and improvement in quality of life. No difference was detected in rates of stroke, atrial fibrillation, or heart failure hospitalizations. There was no significant reduction in mortality or heart failure with atrial- based pacing. At 1 year, rates of death and first hospitalization for heart failure were significantly increased in the dual-chamber group. This trial examined whether the application of newer technologies to limit frequency of ventricular pacing could lead to a decrease in atrial fibrillation in patients with dual-chamber pacemakers. Despite considerable technologic advances in the design and implantation of cardiac pacemakers, approximately 1 in 10 patients ultimately experience a pacemaker-related adverse event. These events are typically related to the pulse generator, surgical pocket, or transvenous lead. Recently, a fully self-contained, leadless cardiac pacemaker has been developed that combines the battery, electronics, and electrodes in a small casing which can be delivered transcutaneously through the femoral vein. A docking interface on the proximal portion of the device provides both delivery and retrieval capabilities. Several small nonrandomized studies have demonstrated leadless pacemaker systems can be safely implanted and provide durable single-chamber pacing from the right ventricle. Advances in physiologic sensors and rate adaptation algorithms include the following. For example, a desirable sensor combination is an activity sensor, which typically has a more rapid response, and another sensor such as minute ventilation, which typically has a more delayed but workload- proportional response. Sensor blending refers to the relative contribution of each sensor during each phase of activity and may be programmable. Sensor “cross-checking” is done to determine if an increase in the intrinsic atrial rate is appropriate. If the sensor does not confirm activity while the pacemaker senses an increased atrial rate, the pacemaker will use the sensor to dictate the appropriate heart rate. Also, pacemakers with multiple sensors are able to detect intersensor disagreement and thereby avoid inappropriately rapid pacing because of a false-positive response of one sensor. The anode of a bipolar pacing system is the proximal ring electrode of the pacing lead. The minimal electrical energy required to consistently depolarize cardiac tissue through a given electrode. This threshold changes with time after implantation (acute, subacute, and chronic). The cathode of a unipolar pacing system is the electrode at the distal portion of the pacing lead.

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In liver disease buy generic viagra super active 25 mg on line erectile dysfunction remedies, stoma­ cholesterol generic viagra super active 25mg online zyrtec causes erectile dysfunction, with a proportionate increase in lecithin tocyte formation has been attributed to an increase and with a decrease in ethanolamine. In hereditary spherocytosis and autoimmune Morphology of blood cells 93 chlorpromazine exposure can cause stomatocytosis in vivo as well as in vitro since an association has been observed [120]. Stomatocytosis in hereditary high red cell membrane phosphatidylcholine haemolytic anaemia is associated with numerous target cells [95]; this condition is now thought to be identical to hereditary xerocytosis [123]. Stomatocytosis has been associated with some cases of hereditary haemolytic anaemia associated with adenosine deaminase over‐ Fig. Increased stoma­ tocytes have been reported in association with target cells in a single patient with familial hypobetalipo­ proteinaemia [112], but in the published photograph the target cells are much more convincing than the stomatocytes. An increased incidence of stoma­ tocytosis has been reported in healthy Mediterranean (Greek and Italian) subjects in Australia [124]. This condition, designated Mediterranean stomatocyto­ sis/macrothrombocytopenia, is now known to be a manifestation of hereditary phytosterolaemia [125]. A sickle cell is a very specifc type of cell that is con­ Stomatocytes have been associated with a great var­ fned to sickle cell anaemia and other forms of sickle iety of clinical conditions [119,120] but an aetiologi­ cell disease. Sickle cells are crescent‐ or sickle‐shaped cal connection has not always been established. The characteristic shape commonest cause of stomatocytosis is alcohol excess is very apparent on scanning electron micrography and alcoholic liver disease; in these cases there is (Fig 3. The blood flm in sickle cell anaemia may often associated macrocytosis and in those with very also show boat‐ or oat‐shaped cells (Fig. They are also common in erythroleukaemia Howell–Jolly body is a fragment of nuclear material. Similar cells can be seen in oxidant‐induced hae­ arise by karyorrhexis (the breaking up of a nucleus) or by molysis, when they result from removal of two adjacent incomplete nuclear expulsion, or can represent a chromo­ Heinz bodies. Searching for Howell–Jolly bodies is a reliable tech­ nique for screening for signifcant hyposplenism, although a phase‐microscopy pitted cell count is more sensitive and will also detect milder impairment of splenic function [127]. They are composed of aggregates of ribo­ somes; degenerating mitochondria and siderosomes may be included in the aggregates, but most such inclusions are negative with Perls acid ferrocyanide stain for iron. Increased numbers are seen in the presence of thalassaemia minor (particularly β thalassaemia trait and Fig. Some Howell–Jolly bodies are found in general (including congenital dyserythropoietic anaemia, erythrocytes within the bone marrow in haematologically sideroblastic anaemia, erythroleukaemia and primary mye­ normal subjects but, since they are removed by the spleen, lofbrosis), liver disease and poisoning by heavy metals such they are not seen in the peripheral blood. Baso­ the blood following splenectomy and are also present in philic stippling is a prominent feature of hereditary def­ other hyposplenic states, including transient hyposplenic ciency of pyrimidine 5’‐nucleotidase [128], an enzyme that states resulting from reticulo‐endothelial overload. Inhibition of this enzyme can be a normal fnding in neonates (in whom the spleen may also be responsible for the prominent basophilic stip­ is functionally immature). Pappenheimer bodies in a haematologically normal subject, small numbers of Pappenheimer bodies (Fig. In pathological conditions, such as lead poisoning numbers in erythrocytes; they often occur in small clus­ or sideroblastic anaemia, Pappenheimer bodies can also ters towards the periphery of the cell and can be dem­ represent iron‐laden mitochondria or phagosomes. They are composed of ferritin patient has also had a splenectomy they will be present in aggregates, or mitochondria or phagosomes containing much larger numbers. They stain on a Romanowsky stain because clumps of ribosomes are co‐precipitated with Cabot rings the iron‐containing organelles. A cell containing Pap­ Cabot rings are remnants of microtubutes that formed penheimer bodies is a siderocyte. Courtesy of Dr Anna Merino and colleagues, Barcelona, and of cells whereas rouleaux (Fig. The most common causes are preg­ nancy (in which fbrinogen concentration is increased), infammatory conditions (in which polyclonal immu­ noglobulins, α2 macroglobulin and fbrinogen are increased) and plasma cell neoplasms such as multiple myeloma (in which increased immunoglobulin con­ centration is caused by the presence of a monoclonal paraprotein). Rouleaux formation may be artefactually increased if a drop of blood is left standing for too long on a microscope slide before the blood flm is spread. Abnormal clumping of red cells can also occur in patients receiving certain intravenous drugs that use polyethoxylated castor oils as a carrier (e. It has been observed, together with eryth­ of a paraprotein; the flm also shows increased background rophagocytosis, in paroxysmal cold haemoglobinuria [136]. Reticulocytes may form agglutinates when their Leucocytes numbers are increased; this is a normal phenomenon. Mature red cells agglutinate when they are antibody‐ Normal peripheral blood leucocytes are classifed either coated. Small agglutinates may be seen in warm auto­ as polymorphonuclear leucocytes or as mononuclear immune haemolytic anaemia. Agglutinates are more cells, the latter term indicating lymphocytes and mono­ common in paroxysmal cold haemoglobinuria and in cytes. Polymorphonuclear leucocytes are also referred chronic cold haemagglutinin disease there may be mass­ to as polymorphonuclear granulocytes, polymorphs or ive agglutination (see Fig. The term ‘granulocyte’ has also been used Rouleaux formation is increased when there is an to refer more generally to both the mature polymor­ increased plasma concentration of proteins of high phonuclear leucocytes usually seen in the peripheral Fig. Polymorphs divided into two to fve distinct lobes by flaments, which have lobulated nuclei, which are very variable in shape, are narrow strands of dense heterochromatin bordered hence ‘polymorphic’, and prominent cytoplasmic gran­ by nuclear membrane (Fig. The nucleus tends to ules, which differ in staining characteristics between follow an approximately circular form since in the living the three classes – neutrophil, eosinophil and basophil. In normal females a ‘drumstick’ may be seen of the monocyte they are inconspicuous, whereas in protruding from the nucleus of a proportion of cells (Fig. In pathological conditions and in certain through the cytoplasm, but there may be some agranular physiological conditions, such as pregnancy and dur­ cytoplasm protruding at one margin of the cell. This may ing the neonatal period, precursors of polymorphs may represent the advancing edge of a cell in active locomotion. Characteristics of the nucleus The terms ‘polymorph’ and ‘granulocyte’ should not be The neutrophil band form and left shift used to refer specifcally to neutrophils, since these des­ A cell that otherwise resembles a mature neutrophil but ignations also includes eosinophils and basophils. The Granulocytes Committee for the Clarifcation of Nomenclature of Cells and Diseases of the Blood Forming Organs has defned the neutrophil a band cell as ‘any cell of the granulocyte series which The mature neutrophil measures 12–15 μm in diameter. The coiled band, no matter how marked the indentation, if visible granules are not the secondary granules of the neu­ it does not completely segment the nucleus into lobes trophil, which are below the level of resolution of the light separated by a flament’. Rather, they are primary granules that have connection with ‘no signifcant nuclear material’ [137]. Although they are A band is differentiated from a metamyelocyte (see not individually visible, it is the specifc neutrophil gran­ below) by having an appreciable amount of nucleus ules that are responsible for the pink tinge of neutrophil with parallel sides. The disposition of the nuclear lobes around the circumference of a circle is apparent. Inconsistency between laboratories with regard to defnition is common, as is variation between and within laboratories as to how defnitions are applied. Band cell counts have been employed in the detection of infection in neonates, but again various defnitions have been applied [138,139]. A left shift contributes to the Alvarado score for the presumptive diagnosis of acute appendicitis [141].

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The latter was eye-catching purchase viagra super active 25mg amex varicocele causes erectile dysfunction, and alcoholism is associated with mac- include presence of uncontrolled diabetes purchase viagra super active on line amex impotence vs impotence, obesity, and rocytosis, due to nutritional deficiency. Hemo- stigmata of cirrhosis is appropriate as well (spider chromatosis is much more common than appreciated angiomata, palmar erythema, testicular atrophy, dis- decades ago. However, that relationship is not indicated in the absence of abdominal pain and bil- neither quite sensitive nor specific. Approximately 15% of patients with laboratory findings from constant drinking will develop 9. Conjugated bilirubine- cirrhosis even though one-third will have fatty liver at one mia (direct-acting bilirubin), when in the absence of time or another. Other tests and procedures can be unconjugated bilirubin, indicates extrahepatic obstruc- deferred to results of further inquiry, and empiric response tive jaundice. The diagnosis is in obstructive jaundice, but neither confirms nor rules confirmed by endoscopic retrograde cholangiography, out obstruction; if obstruction is present, no anatomic which usually shows evidence of extrahepatic ductal diagnosis will be made from the test. Patients are commonly complicated by bacterial ascending cholangi- asymptomatic for years before beginning complaints of tis. Antimitochondrial anti- unlikely in the absence of colic and gallstones in the gall- bodies are positive in 95% of cases, although the test is bladder. Alcoholic cirrhosis is not charac- asymptomatic conditions such as diabetes, morbid obe- terized by the skin manifestations alluded to and is not sity, and alcoholism and in itself would not cause the characterized by the symptoms of biliary obstruction symptoms in the vignette. Autoimmune hepatitis is initially a “painless jaundice” with a palpable gallbladder (the diagnosis of exclusion in a patient who manifests evidence Courvoisier sign). Gilbert disease (or syndrome) is a mild of acute, subacute, or chronic hepatitis without evidence condition in which there is an inherited tendency for of viral, chemical, infectious, or pharmacological causa- intermittent elevation of unconjugated bilirubin levels. The dis- chronic nor does it result in a carrier state, nor does hepa- ease is characterized by copper overload, damaging the titis E. Hepatitis D may be transmitted by become symptomatic until late middle age for men and percutaneous or nonpercutaneous means; it requires later still for women. Hepatitis E is transmitted mainly by fecal–oral contamination; it generally risks no complica- fecal–oral contamination; it is fraught with no complica- tions. Mildly elevated liver transaminase levels in the as- chronic hepatitis and sexual transmission. Current Medical Diagnosis and Treat- induced hepatitis, but there is less risk of sexual and acci- ment 2010, 49th ed. Pelvic exam- ination shows a first degree urethrocele and involun- 3 Which of the following is the organism most likely to tary passage of urine when she bears down. She denies gastrointestinal symptoms, cough, (A) Intravenous urogram coryza, and pain in specific areas. He was alarmed when he noticed some chemotherapy) blood at the beginning of the urinary stream. A uri- (D) Persistent nausea and vomiting nalysis from split specimens (beginning, middle, and (E) Discovery of an anatomical basis for the terminal stream) confirms microscopic and chemical pyelonephritis (e. Which 6 In which of the following categories of patients is of the following is the likely site of the hematuria? Which is the become sexually active over the past 3 years and had most likely causative organism? She has (A) Pseudomonas aeruginosa otherwise been in good health and is not taking med- (B) S. She (E) Vaginal seeding by coliform bacteria denies abdominal pain, dysuria, and frequency. Which of the following is the (A) Uric acid in hyperuricemia best first working diagnosis? Costovertebral angle tenderness in an would not be appropriate in the treatment of stress uncomplicated case is not an indication for hospitaliza- incontinence. However, each of the other factors rine and phenylpropanolamine stimulate the bladder mentioned are such indications. The treatment failure, sepsis or suspected sepsis, age 60 years, tricyclics such as imipramine have both 1 adrenergic inadequate access to follow-up care, and uncertainty of agonist effects and anticholinergic activity, the latter diagnosis. Clean intermittent catheterization has a place with both stress incontinence and hypotonic 6. A patient with fever, pyuria, and sug- as well as a lower risk of low birth weight babies and of gestions of systemic illness or symptoms more specific for preterm delivery. In no other category, culture of asymp- upper tract involvement has a 98% chance of having tomatic patients is supported by evidence at this time. Chances are quite good, but not certain, that upon examination she will manifest definite costo- 7. Urolithiasis mani- in the vagina and introitus can easily ascend through the fests colicky lateralizing pain, at least when the stone is urethra into the bladder. Bladder cancer and hypernephroma (renal cell raises vaginal pH and creates a more favorable vaginal carcinoma) are notorious for painless hematuria with no and periurethral environment for these bacteria. Trigonitis is a syndrome encountered in about 1% of adult women (nongeriatric) with recurrent mature females consisting of irritative bladder symptoms cystitis have an identifiable anatomic abnormality. Oral contraceptives, for example, tis also involve Pseudomonas but usually not Candida increase in vaginal secretions, providing a culture medium organisms. Immunosuppressed patients tend to develop for bacteria and contamination of clothing near the anal subclinical pyelonephritis caused by nonenteric, aerobic orifice. The answer is D, magnesium ammonium phosphate treatment of this serious infection comes first. These are called stru- antibacterial therapy can be started, a culture and sensi- vite stones, and insofar as they become molded by the tivity must be obtained to avoid wasting precious time in calyceal collecting system, they are often referred to as treating with ineffective anti-infectious agents while risk- “staghorn” calculi. The diagnostic studies mentioned are urease, which causes the hydrolysis of urea to ammonia important but should take place after therapy is underway and carbon dioxide. Vesi- likely the cause of the hematuria and, in this case, an coureteral reflex is the most likely urinary tract abnor- infection. A voiding The split specimen results would be similar in the case of cystourethrogram is the most common initial diagnostic urethral trauma as in vigorous sexual activity. Hematu- tool but is not used for follow-up because of the radiation ria found through all three specimens, total hematuria, exposure. A radionuclide study for reflux involves less points toward bladder or kidney for the cause. Terminal radiation exposure and appears to be more sensitive once hematuria suggests bladder neck, prostate, or trigon the fact of reflux is established. With bladder distention or with suspected resistant organisms), the percentage of the segment fails to shut off retrograde flow of urine with cases of cystitis caused by E. Although in a given clinical setting for the vast majority of reflux and upper genitourinary painless hematuria cancer may not pose even a majority tract spread of infection. A significant portion of this excess cell carcinomas of the bladder or renal cell carcinoma (in morbidity, but not enough to account for it alone, is the past often called hypernephroma). Occasionally the attributed to noncircumcised male infants; thus, Choice E lesion may be so small as to be missed grossly. Female repeated as long as the cause of painless hematuria, par- children, especially those over the age of 5 years, may be ticularly microscopic hematuria, remains unexplained. Cigarette smoking is easily the stron- cystitis is common in women, usually younger than the gest risk factor for bladder cancer in western society that woman presented in the vignette, and is always charac- is found in male:females 2:1.

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Dacie & Lewis Practical Haematology purchase viagra super active 25mg without a prescription erectile dysfunction treatment caverject, 9th edn purchase viagra super active cheap online impotence with prostate cancer, Edinburgh: Churchill livingstone, 2001. However, we have provided the more important tests in current use which include: • Blood group and antibody screen. Safe transfusion practice Each year, patients are transfused with the wrong blood. However, it is also clear that delay in appropriate transfusion also contributes to mortality. A common error is clerical and generally involves the cross-matched sample being taken from the wrong patient, and so the compatibility test is performed on the wrong sample. Occasionally, the staf carrying out the transfusion connect the blood up to the wrong patient. How to minimize errors • First, ask yourself, ‘Does this patient really need to be transfused with blood or blood products (e. Use clinical judgement in helping decide whether or not to proceed with transfusion. Many transfusion laboratories insist on 1, 2, 5, 6, and 7, and either 3 or 4 from: 1. If this sounds cumbersome and bureaucratic Remember many people die annually because they are transfused with the wrong blood. In most cases, clerical error is to blame—people have flled out bottles in advance and failed to check patient identity. If the temperature rises to above 39°C or >2°C from baseline, with other signs/symptoms, consider bacterial contamination and monitor the patient carefully. Immediate transfusion reaction or bacterial contamination of blood If predominantly extravascular, may only sufer chills/fever 1h after starting transfusion—commonly due to anti-D. Mechanism Complement (C3a, C4a, C5a) release into recipient plasma l smooth muscle contraction. Initial steps in management of acute transfusion reaction • Stop blood transfusion immediately. Urgent investigations your local blood transfusion department will have specifc guidelines to help you with the management of an acute reaction. The following guide lists the samples commonly required to establish the cause and severity of a transfusion reaction (see Box 3. If you are uncertain about the labora- tory procedure or management of a patient who appears to have sufered a severe reaction, you must notify your hospital’s haematology medical staf who will provide advice. Mainly due to anti-HlA (human leu- cocyte antigen) antibodies in recipient serum or granulocyte-specifc anti- bodies (e. Check the compatibility label of the blood unit matches with the patient’s identity band, forms, and case notes. If mistake found, tell the blood bank urgently—the unit of blood intended for your patient may be transfused to another patient. Implicated organisms include Gram −ve bacteria, including Pseudomonas, Yersinia, and Flavobacterium. Background If an Rh (D) −ve mother has a baby that is Rh (D) +ve, she may develop antibodies (maternal anti-D) against fetal red cells. This may result in fetal red cell destruction termed rhesus haemolytic disease of the newborn, a seri- ous haemolytic disorder that is seen less today due to a greater understand- ing of the underlying mechanism and our ability to prevent it. The Kleihauer test should be performed on all Rh (D) −ve women who deliver an Rh (D) +ve infant. Fetal cells appear as darkly staining cells against a background of ghosts (these are the maternal red cells). An estimate of the required dose of anti- D can be made from the number of fetal cells in a low-power feld. After this, you will need to calculate the dose of anti-D to give the mother, but if you are unsure, either discuss with the haematology medical staf or contact your local transfusion centre. The typical anaemia found in renal disease is a result of failure of Epo production. For example, in the assessment of polycythaemic states, an i Epo level may be appropriate (e. Tests for antiplatelet and antineutrophil antibodies These tests are usually requested by the haematology department for patients with either thrombocytopenia or neutropenia, respectively. These assays are used to detect the presence of specifc antibodies against platelet or neutrophil antigens on the cell surface. These are useful for detecting even weak antibodies or where there are only a few antigenic sites per cell. Elegant though these tests are, they are actually not useful in clinical prac- tice for the diagnosis of neutropenia or thrombocytopenia where the cause is autoimmune, since these are largely clinical diagnoses. Most cells will express many diferent proteins, and the pattern of expression allows cellular characterization. Using a panel of diferent antibodies, an immunophenotypic profle of a sample is determined. Immunophenotyping is used in conjunction with standard morphological analysis of blood and marrow cells. The antibodies are labelled with fuorescent markers, and binding to cell proteins is detected by laser. Oxford Handbook of Clinical Haematology, 2nd edn, Oxford: Oxford University Press, 2004. Clonality assessment Particularly useful in determining whether there is a monoclonal B-cell or plasma cell population. Guidelines on the use of multicolour fow cytometry in the diagnosis of haematological neo- plasms. Chromosome abnormalities may be constitutional (inherited) or acquired later in life. Cytogenetic analysis of chromosome structure and number has been used for many years for the study of disorders such as Down’s syndrome. Acquired chromosomal abnormalities are found in malignancies, especially haematological tumours. The analysis and detection of cytoge- netic abnormalities is known as karyotyping. Because of the complexity of this subject area, we will concentrate on two main areas where chromo- some analysis is of value. Cytogenetic assays are expensive (around £250 for a leukaemia or lym- phoma karyotype), and if there is any doubt as to whether the test is indi- cated, we would suggest you discuss the case with one of your seniors or the cytogenetics staf. Arranging karyotyping before or during pregnancy is generally carried out by the obstetrician in charge of the woman’s care. Pre-implantation genetic diagnosis allows abnormalities to be detected even before implantation has occurred. Chromosomes are examined directly using light microscopy or with the aid of a computerized image analysis system.

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