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This assumption has its own limitations 100mcg synthroid amex symptoms magnesium deficiency, however buy 125mcg synthroid otc medications prescribed for adhd, especially since passive movements of the joint will still cause some movement of the soft tissues purchase synthroid 50 mcg without a prescription symptoms prostate cancer. Myofascial pain is said to occur when there is activation of a trigger point that elicits pain in a zone stereotypical for the individual muscle buy synthroid 75 mcg low price symptoms cervical cancer. It is not clear whether trigger points are the same as the tender points characteristic of fibromyalgia. Do not dismiss the report of focal pain (or think of it as referred only) if there is no tenderness at the site on static examination. However, the technique is reliable only if localization of the injected anaesthetic can be guaranteed. Few, if any, rigorously controlled trials have shown it to give specific results for any condition. Typically, patterns of pain referral extend distally so problems at one joint can cause symptoms in the area of the adjacent distal joint. It may be a manifestation of inflammation or reduced movement due to mechanical pathology including swelling, or be used by an individual to describe reduced movement due to pain • Stiffness is often worse after a period of rest. Short periods (<30 min) of stiffness that persist after mobilizing is not a meaningful observation. Stiffness lasting >30 min and often several hours after mobilizing is a typical symptom of inflammatory arthritis. Individuals typically click or crack their joints to stretch the tissues and gain relief. Regard ‘swelling’ as a sign on examination unless the description of it as a symptom is convincing and the story has been elicited very carefully. Clunks, snaps, and clicks • ‘Clicks’ are often the focus of symptom reports and can cause some anxiety. However, ‘clicks’ from many different structures are not specific for ‘pathology’. Constitutional symptoms Fatigue, fevers, sweats, and excessive sweating sometimes occur with many different rheumatological diseases. Rashes There are many rheumatological conditions that are manifest in part by rashes. The association may be temporally related or separate in time so a broad view of the history of the rash needs to be taken. An atlas of typical psoriasis appearances is a very useful tool in the rheumatology clinic. Look for operation movements scars and Wrist extension and flexion ‘With the elbows in the palpation same position place the hands back to back with the fingers pointing down’ Elbows: look for nodules, rash ‘Bend your elbows bringing your hands up to your shoulders’ Shoulders: ‘Raise arms sideways, up Abduction to 180° to point at the ceiling’ Rotation ‘Touch the small of your back’ Hips, knees, Hips: lift leg (bended knee) and position upper leg vertical. With the patient standing upright, make a horizontal mark across the sacral dimples and a second mark over the spine 10 cm above. Pain assessment in children and adolescents Introduction More apparent in children, than at other ages, is that the level of distress from pain does not correlate well with the severity of the underlying or causative pathology. Pain assessment in specific scenarios The non- or minimally verbal child In the very young, or those with cognitive or emotional impairment, the history of pain and its impact is sought from the parent or carer and correlated with an astute clinical examination that looks for distress. Both can be carefully corroborated during examination feeling for, but not trying to overcome, any resistance to joint movement and monitoring facial expressions. The toddler and school-aged child • Children from <3 years old can volunteer helpful information and attempts to engage them in friendly discussion will provide reassurance before examination. Use of a picture or cuddly toy may help to localize the site of pain and the use of the Faces Pain Scale is a standard tool to indicate pain intensity, see: http://www. Swelling may arise from subcutaneous tissues, tendons, or joints, and may include oedema, lymphoedema, cellulitis, and haematoma. Teenagers • By speaking directly to the young person, a more accurate clinical picture will be acquired than from speaking to parents alone. Early morning wakening with pain may be associated with inflammatory or malignant conditions, whereas difficulty with sleep initiation or maintenance may be associated with chronic pain. Most cases of acute limp, however, have a preceding illness and are diagnosed as irritable hip or transient tenosynovitis. Subacute or long-standing limp or concerns about gait may present to rheumatologists. Age-specific assessment Toddlers and pre-school children • Review the child with reference to normal development and spend time observing the gait, first noting normal variants (see pp. Fatigue • It is unclear from what age children report negative experiences of generalized exhaustion, which as in adults may accompany any illness, but it may be reported by parents as a presenting symptom. In this way, a full screening joint examination can be played out as a game without touching the patient initially, thereby building rapport and patient confidence. Temporomandibular joint movement should allow three fingers of the patient’s hand to be held vertically in their open mouth. Chronic severe pain, lasting >3 months and affecting quality of life, is common too, with a prevalence of up to 16% in secondary school-aged girls. In this respect, pain is not a sensitive marker of disease yet it is still important to provide reassurance to avoid symptom amplification and prolonged disability. Although not the convention in paediatrics, we have taken a threshold of 3 joints to define multi-articular involvement: • mono/oligoarticular arthritis in children (1–2 joints). Early metastasization is associated with increased mortality necessitating early recognition. Key features which should trigger referral for further assessment in children and adolescents • Limp (see also ‘Assessment of the limping child’ pp. For example, these features might lead to disclosure of: • septic arthritis or osteomyelitis (high fever, hot and tender joint, or limb pain). These changes should not be dismissed as behavioural or anxiety induced (whether parent or child) without plans for a timely review of resolution or progression. The onset of muscular dystrophies, congenital and metabolic myopathies, and neuropathies are often insidious in onset. Muscle weakness, muscle fatigue, numbness, and delayed development predominate but may be associated with widespread or focal pain that is the presenting feature. There can be complete school absence and grossly abnormal sleep routines attributed to pain. Care must be taken when using the term ‘hypermobility’ as it can be perceived as disabling with a poor outcome. The cause of pain is often complex, but with effective communication and a range of integrated strategies that includes a focus on self-management and resilience, the outcome will be excellent with full participation in a normal quality of life. Functional weakness, not attributable to fear of movement from pain, may be indicated by walking on tiptoes and difficulties climbing stairs, and putting on T-shirts or jumpers. The 3 ‘Ss’: Stiffness, Swelling, and a positive Squeeze test (pain elicited by squeezing the knuckles). Assessment of children and adolescents Normal variants Effective reassurance that a child has a normal variant avoids unnecessary referral, investigation, and intervention. Causes toeing/out- include metatarsus adductus, toeing femoral anteversion, and tibial torsion. Refer >9 yrs if gait affected Toe walking 7–24% of children Usually resolves by 3 yrs.

A blank control dial (linked to a computer) is Vaporizer output may be affected when the carrier gas attached and rotated at various carrier gas fow rates order generic synthroid line medications bipolar disorder. This is due to changes in viscosity output concentration is measured using a sample that and density buy discount synthroid 200 mcg online medications 7, which alter the performance of the fow- is analyzed by a refractometer (see Fig buy synthroid master card medicine chest. Increasing the concentration of nitrous (which has a unique serial number) is then removed and oxide reduces the vapour concentration buy cheap synthroid 125 mcg line medicine 4211 v. This is of little a calibration scale etched onto it from the information importance in clinical practice at present. It is then re-attached to that same interest in the gas xenon (which is fve times as heavy as vaporizer and the calibration confrmed prior to leaving air), as a potential anaesthetic, may change this. Vaporizers may also have the calibration con- also a further mechanism causing a change in vaporizer frmed in a similar manner, following servicing. These systems were criticized and have largely disappeared from use as the vaporizer could easily be flled with the wrong agent. Despite this, they are still supplied by all the major manufacturers for certain countries (Fig. In these the distal end was keyed to ft a vaporizer calibrated, labelled and colour coded for a specifc agent and the proximal end keyed to ft only the neck of the bottle for that agent (Fig. Although these devices go some way to reducing the potential for flling vaporizers with the wrong agent, it is by no means foolproof. Note that the top has unique grooves (shape, colour and position) that ft only the specifc flling ports on matching vaporizers. When the vaporizer is attached to the back bar of an anaesthetic workstation, gasses destined for the patient pass through it via three channels. From here the gasses pass across the top of the vaporizer, without coming into contact with the vaporizing chamber and leave through the outfow (9). The vaporizer channel has an elongated passage (2) that funnels carrier gas into the centre of the wick assembly. This comprises a hollow tube of Tefon cloth held open by a steel wire spiral and wound into a helix (3) within the vaporizer. This arrangement greatly increases the surface area for vaporization over previous Tec models. The A B gas passing through the wicks becomes saturated with vapour and enters a rotary valve assembly (calibrated Figure 3. Note that the fller The second channel guides bypass gas through the base on the bottle is secured by a crimped metal seal. Similarly, of the vaporizer, through the temperature compensating a sealed bottle of desfurane; with Saf-T-Fil system. The percentage of vapour at the outlet and desfurane (Baxter) produce sealed bottles to which depends on the amount of vapour-laden gasses that is the agent-specifc flling device is already ftted and made mixed with the fresh gasses passing through the bypass. These flling As the temperature within the vaporization chamber falls devices also have valves, which are only opened when (reducing the vapour concentration produced), the ther- inserted fully into their respective fller ports, so as to prevent mostatic valve closes. The flling system for sevofurane the total gas fow to pass through the chamber; by this and the older agents can be designated at ordering of the means the vapour concentration in the output is kept vaporizer but sevofurane from Abott Laboratories only uses constant. If two Although it is increasingly diffcult to fll a vaporizer vaporizers with this latter feature are placed on a back bar with the wrong drug, it is far easier to fail to fll a vaporizer (see below), the frst vaporizer to be switched on extends because of the multitude of flling systems between drug lateral rods that impinge on the adjacent vaporizer pre- and vaporizer manufacturers. Also, the vaporizer dial cannot be turned if the vaporizer is improperly mounted on the anaesthetic machine, i. It has: Blease is now part of Spacelabs Healthcare and the vapor- izer range is now labelled as Spacelabs Healthcare. Working principles: (1) fresh gas input, (2) control dial, (3) zero lock, (4) thermal 2 2 compensator rod, (5) fller block for agent-specifc device, 1 1 (6) agent reservoir, (7 and 9) wick extension, (8) elongated Tefon wick, (10) vapour control valve, (11) combined gas 0 0 15 20 25 30 35 and vapour output, (12) variable resistance bypass valve. Performance characteristics for variations in temperature C Temperature (C) and fow. The earlier version had a stainless steel outer cover- gasses split into two fows with one part initially fowing ing but this was separated from the brass body of the vapor- through a series of baffes (2) that counteract pressure izer by a layer of plastic. From here, it is directed improve the absorption of radiant heat from the surround- through the vaporizing system, where it becomes saturated ings and has enabled less brass to be used. This takes the form of a tubular wick (3) of the vaporizer helps to seat the vaporizer frmly on the coiled in a spiral, through which the gas passes. The outer back bar when it is connected to the anaesthetic worksta- surface of the spiral is attached to a sleeve of similar mate- tion and so reduces the potential for leaks. The working rial (4) that dips into the liquid anaesthetic agent in the principles of the vaporizer are shown in Figure 3. Therefore, a stabilizing This is wound into a spiral to create a large surface area agent, such as thymol that is added to halothane, will for contact with carrier gas that passes through the tube. This allows At the base of the spiral, the Tefon is made to drape into the vaporizer to be used for prolonged periods between the liquid reservoir (7). From here they pass to a mixing that isolates the vaporization chamber so that all the chamber (9), where they blend with bypass gasses prior patient designated gas travels through the bypass. One passes of the latter drops, a compensating device (8) (see also through the elongated wick (8), collecting vapour; Figs 3. The bi-metallic device consists Penlon Sigma Delta vaporizer of a central rod made of Invar, a metal alloy with a low coeffcient of expansion, part of which sits inside a brass The Penlon Sigma Delta, shown in Figs 3. A closing mechanism (not shown) prevents on when it is not connected to a machine and so if this is any gasses coming into contact with anaesthetic vapour left on and the vaporizer is inadvertently tipped, there is the in the vaporizer. When the control knob (4) is turned on, the closing However, the relevant channels are placed towards the front mechanism is released and a second channel is opened of the vaporization chamber near the fller block. If the that ducts a portion of these gasses through the vaporizing vaporizer falls on its side, the fller block prevents these system. They pass initially through a helical damping coil channels from being submerged in liquid agent. Dräger ‘Vapor’ 2000 series From here they pass into the vaporizing chamber (6) and around the wick (7). The latter is novel in that it is of vaporizers made of sintered polyethylene (1 m long), which is held Figures 3. Models in the range are all then coiled into a spiral, the top and bottom of which compensated for temperature and pumping effects. The wick assembly is (9) is placed in the vaporizing chamber, so that its base is designed as a cartridge for ease of removal and cleaning, immersed in the vaporizing liquid. Gasses saturated with anaesthetic vapour leave the The vaporizer is interesting in that it is relatively light chamber and pass through an orifce whose aperture is (5 kg), being made of aluminium. Aluminium has a better varied by a needle valve (8) attached to the control thermal conductivity than brass and so, despite its weight, knob. The latter, therefore, controls the amount of vapour- it conducts a similar amount of radiant heat as does an laden gasses fowing through the device to mix with the equivalent sized brass device. Working principles: (1) gas input, (2) damping the chamber, (3) tubular wick, (4) wick extension, (5) reservoir chamber, (6) concentration control valve, (7) calibration dial, (8) temperature compensation device, (9) mixing a chamber, (10) output, (11) bypass tap, (12) bypass tap. In systems All the plenum vaporizers described above offer resistance A–D, exhaled gasses are vented to the atmosphere and to the gas fow. E, the patient’s exhaled gasses are recirculated through However, pressurized gas sources are not always available the vaporizer. Note that they all contain non-return valves to prevent reverse fow through the vaporizer.

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Every 5 mm of distal translation of the vertical bar will increase the tibial slope by about 1° (Fig cheap synthroid online visa 9 medications that can cause heartburn. A tibial stylus is placed through the cutting slot to measure the depth of the tibial resection (Fig discount synthroid medicine 3604. A small straight osteotome is used to link the two cuts buy synthroid with mastercard treatment 2, and a broader osteotome is used to lever the resected bone and remove it purchase synthroid master card treatment centers near me. If it is too shallow, the cutting block is lowered by replacing it through a higher hole in the cutting block, and the cut is redone. The goal is to have 7 mm of space for an all-polyethylene bearing and 10 mm if a metal- backed bearing is needed. Flex or extend the knee until this proximal tibia, as plateau fractures can result. Move the guide so that it does not overhang superi- orly to prevent patellar clunk. The anterior chamfer cut is made next to remove a small piece of the previously gouged bone. Step 5: Trial Reduction • Place a femoral trial prosthesis in the center of the medial femoral condyle. Move it medially or laterally to allow it to best articulate with the tibial trial prosthesis (Fig. This will • If the trial is tight in extension, cut 2 more millimeters of distal femur. Step 6: Final Femoral Preparation • Place the knee in 90° of fexion to expose the distal femur. Step 8: Final Prosthesis Implantation • All the trial prostheses are removed and the joint is irrigated with saline to remove all the blood in the bone. This allows the surgeon to remove • The tourniquet is defated and all miscellaneous bleeders are cauterized. Younger patients and those with a thinner polyethylene component had a higher rate of failure and revision. Survival rates at 9 years were better when the polyethylene component was thicker than 7 mm and when the shelf life was under 1 year. Endres S, Steinheiser E, Wilke A: Minimally Invasive Stryker-Osteonics unicondylar knee prosthesis with metal-backed tibia component: a 5-year follow-up, Z Orthop Ihre Grenzgeb 143:573–580, 2005. At 1 year, using the Insall and Scott Clinical Rating System, the patients’ knee score improved from 57. Forty-fve patients were randomized to two groups, one received an all-polyethylene tibial component and the other received a metal-backed tibial component. The authors used radios- tereometric analysis to measure micromotion of the tibial component for 2 years after surgery. No signifcant difference was seen between the two groups, and therefore the authors recommended using an all-polyethylene component because of its lower cost, excellent biomechanical strength, and lack of modularity. Between 1985 and 2003, 1819 patients entered in the Finnish Arthroplasty Register were studied for prosthesis survival using Kaplan-Meier analysis. While progression of osteo- arthritis was similar in both groups, the mobile bearing group had a lower incidence of lucency on radiograph. Earlier implants used “inlay” techniques to blend with the native trochlea C and were at high risk of failure in patients with D dysplasia. The implants are trialed for a fnal time, and fnal assessment is made for the need for lateral reti- nacular lengthening or suprapatellar fat or synovial resection (Figs. Hutt J, Dodd M, Bourke H, Bell J: Outcomes of total knee replacement after patellofemoral arthroplasty, J Knee Surg 26:219–223, 2013. The incision is carried out to the proximal half of the tibial tubercle on the medial side. This will • Incision and arthrotomy length may be facilitate enhanced exposure during the procedure through enhanced mobilization of minimized by using a “mobile window. The incision is carried out to the proximal half of the tibial tubercle on the medial side. This will • Incision and arthrotomy length may be facilitate enhanced exposure during the procedure through enhanced mobilization of minimized by using a “mobile window. The arthrotomy is then continued along the medial border of the patel- • Incision and arthrotomy length may be minimized by using a “mobile window. The incision ends at the proxi- mal half of the tibial tubercle on the medial side (Fig. This will facilitate enhanced exposure during the procedure through enhanced mobilization of these structures. It is innervated by the terminal branches of the saphen- ous nerve, which is a branch of the femoral nerve (Fig. Increased excursion is typically seen in the lateral compartment, which effectively externally rotates the femoral component relative to the posterior condyles. Adjustment of the cutting block anteriorly or posteriorly will increase or decrease the width of the fexion gap, respectively (Fig. These devices may facilitate gap balancing with less exposure, allow for more quantifable application of tension to the ligaments, and permit easier adjustment of rotation if necessary (Fig. Errors in varus or valgus when cutting the tibia can lead to subsequent • Anatomic landmarks should be used as a errors in femoral component rotation. Potential references include the tibial tubercle, medial the lateral collateral ligament-popliteus tendon border of the tibial tubercle, and posterior tibial cortex. In this tech- nique, tibial component rotation is dependent upon femoral component rotation and soft tissue tension. With the knee in extension, the rotation of the tibial tray is then marked on the tibia (Fig. The tray will usually • Trial components should be used to assess tibial component position and ensure there is be centered at the junction of the medial and central third of the tibial tubercle. This cadaveric investigation identifed the surgical epicondlar axis and suggested the rotational alignment of the femoral component can be accurately estimated using this technique. This study compared knee arthroplasties performed using either a measured resection or gap bal- ancing technique to determine if either operative technique provides superior coronal plane stabil- ity as measured by assessment of the incidence and magnitude of femoral condylar lift-off. When analyzed fuoroscopically while performing a deep knee bend, rotation of the femoral component using a gap balancing technique resulted in better coronal stability. This study examined tibial rotational alignment in 109 primary rotating platform knees. The mean neutral point of the rotating tibial insert was found to be 5° ± 5° externally rotated to the medial aspect of the tibial tubercle. However, 5% of the knees had divergence of over 10° from the medial border of the tibial tubercle. This study examined 25 patients with knee replacements using fuoroscopy to determine the amount of condylar lift-off during weight-bearing deep knee bends.

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Parvovirus infection in normal subjects 424 Chapter 9 causes acute cheap synthroid on line medicine hat mall, transient red cell aplasia associated with a non‐C) [36] can be followed by aplastic anaemia proven synthroid 75mcg medications 377. Patients slight fall in Hb and the disappearance of reticulocytes discount 25 mcg synthroid with amex treatment plans for substance abuse, with chronic infection by any of the hepatitis viruses can and therefore a lack of polychromasia purchase 75mcg synthroid with amex asthma medications 7 letters. In some patients develop haematological abnormalities resulting from there is associated neutropenia or thrombocytopenia. In chronic liver disease and hypersplenism and those with patients with a shortened red cell lifespan, more severe hepatitis C infection can develop cryoglobulinaemia. Some viruses, particularly herpesviruses, trigger a haemophagocytic syndrome, Differential diagnosis leading to pancytopenia. Infection by the Sin Nombre The differential diagnosis of the haematological effects hantavirus has been observed to be associated with of viral infection is complex, since the abnormalities thrombocytopenia early in the illness, with severe car- caused are very variable. The differential diagnoses diopulmonary malfunction being predicted by a con- include the various conditions that can cause lympho- stellation of fve peripheral blood features – thrombo- cytosis, atypical lymphocytes and thrombocytopenia. An apparent viral hepatitis (non‐A, non‐B, or lymphadenopathy, but most have only non‐specifc clinical features, such as fatigue. There is an association with chromosomal instability and acquired chromosomal abnormalities, particularly i(3q), trisomy 3 and dup(3) (q26q29) [38,39], which, remarkably, are present in both kappa‐expressing and lambda‐expressing lymphocytes and therefore cannot be taken as indicative of clonality. Blood flm and count The abnormal lymphocytes include both large lympho- cytes with increased cytoplasmic basophilia, resem- bling those seen in viral infections, and bilobed and binucleated lymphocytes [40] (Fig. Some cells have nucleoli and among these there may also be some resembling prolymphocytes. The diagnosis can be made in patients without an absolute lymphocytosis if cytological and Fig. The abnormal cells appear to represent an expanded population of memory B cells [43], possibly analogous to marginal zone B cells [44]. Although the κ:λ ratio may be abnormal, the atypical population includes both κ‐expressing and λ‐expressing cells. Eosinophils may be cytologically normal or show a greater or lesser Further tests degree of degranulation or vacuolation (Fig. The Immunophenotyping is indicated to exclude a mono- blood flm may also show lymphoma cells, blast cells clonal proliferation of lymphocytes. A proportion of patients with hypereosinophilia, often with cutaneous manifestations of the disease, are found Differential diagnosis to have eosinophilia that is mediated by cytokines (e. The latter diagnosis requires that no evidence of an underlying cause can be Blood flm and count found (see below). The lymphocyte count is usually normal and, if it is ele- Further tests vated, eosinophilia secondary to T‐cell non‐Hodgkin The most important initial step in investigating unex- lymphoma should be suspected. These procedures may provide clues indicating the The differential diagnosis is the same as for reactive direction of further investigation. Use of a panel of antibodies to variable domains of the T‐cell receptor can provide evidence Table 9. Serum immunoglobulin Examination of urine for Schistosoma haematobium Rectal biopsy for Schistosoma mansoni E concentration is usually increased and there may be Serology – antibody tests for strongyloidiasis, toxocariasis, polyclonal hyperimmunoglobulinaemia. If the T lymphocytes can be shown to be abnormal cell population in blood or bone marrow clonal, the eosinophilia may be reactive to an overt or T‐cell receptor gene analysis to establish clonality of T lymphocytes occult T‐cell lymphoma, but if T cells are non‐clonal, Disorders of white cells 427 classifcation as ‘idiopathic’ remains appropriate. It is 1 × 109/1 it is likely that cardiac damage is already likely that certain other cases represent a myeloprolif- present or will occur [51]. The description that follows should Many of the characteristic features are not specifc. Tissue damage from the release of eosinophil granule There is a moderate or marked eosinophilia. Eosino- contents can also occur both in reactive eosinophilia phils often show marked degranulation and vacuola- (see above) and in eosinophilic leukaemia. Degranula- tion, even including completely agranular eosinophils tion and vacuolation of eosinophils can also be marked (Fig. The number of degranulated The patient should be appropriately investigated by eosinophils is of prognostic signifcance. If they exceed history, physical examination and laboratory tests for known causes of eosinophilia. If no cause is identifed, immunophenotypic analysis of peripheral blood lym- phocytes should be performed to identify any popu- lation of lymphocytes expressing aberrant markers [49,50]. If an abnormal population is identifed, T‐cell receptor gene analysis should be performed to seek evi- dence that the abnormal population is clonal [49]. Bone marrow aspiration, a trephine biopsy and cytogenetic analysis are also indicated, since detection of increased blast cells or a clonal cytogenetic abnormality permits the diagnosis of eosinophilic leukaemia. Systemic mas- tocytosis or a lymphoma may also be diagnosed on the bone marrow aspirate or trephine biopsy sections. In some 428 Chapter 9 patients death occurs from the early or late effects of Myeloid leukaemoid reactions tissue damage without the true nature of the condition Leukaemoid reactions rarely simulate chronic mye- having become apparent. The differences are sum- A leukaemoid reaction is a haematological abnormal- marised in Table 9. Causes of myeloid leukaemoid reac- correction of the haematological abnormality did not tions (Fig. In such cases, it is diffcult to be sure that the marrow activity such as severe bacterial infection patient did not have leukaemia coexisting with some (particularly if complicated by megaloblastic anae- other disease. This is so in many of the early reports mia, alcohol‐induced bone marrow damage or prior of an apparent leukaemoid reaction with tuberculo- agranulocytosis), tuberculosis, certain viral infec- sis. Transient abnormal myelopoiesis in neonates with tions, haemorrhage and carcinoma or other malig- Down syndrome (see below) should not be described as nant disease (with or without bone marrow metasta- a leukaemoid reaction. Leukaemoid reactions in carcinoma may precede is more correctly regarded as a spontaneously remitting other manifestations of the carcinoma, sometimes by leukaemia [53]. Considerable numbers of large granular tures and the age range of the two diseases are totally lymphocytes have also been reported in association different, no problem occurs in practice. Knowledge of this syndrome and detection of the flm for post‐splenectomy features will avoid this characteristic cytological features (see above) allow a Fig. Hyper‐reactive malarial sple- or, rarely, autosomal recessive or X‐linked recessive nomegaly can be associated with lymphocytosis with inherited condition. Other causative [73]; however, immunophenotyping is essential to mutations are shown in Table 6. A peripheral Blood flm and count blood picture resembling Sézary cell leukaemia has Apart from changes related to infection, any neutrophils been observed as part of a drug reaction [74]. There may be mild lating plasma cells suffcient to simulate plasma cell anaemia and thrombocytosis, both likely to be the result leukaemia have been reported in a patient with bone of infection. However, Further tests it should be noted that phenotypically abnormal lym- Bone marrow examination usually shows an apparent phoid cells can appear in the blood during lymphoid leu- arrest of myelopoiesis at the promyelocyte stage. Cyclical neutropenia Severe congenital neutropenia Cyclical neutropenia occurs as an autosomal domi- Severe congenital neutropenia occurs either spo- nant inherited condition or sporadically, usually in radically (most often) or as an autosomal dominant children under 1 year of age. The reticulocyte and platelet the world where cytogenetic and molecular genetic count may also cycle and sometimes also the eosino- analysis are not available. The monocyte count may ference between these two classifcations is that in the cycle in opposite phase to the neutrophil count. Blood flm and count haematological neoplasms The majority of patients have leukaemic blast cells Haematological neoplasms should be diagnosed and in the peripheral blood.