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By W. Rune. Cambridge College.

While a physical examination can be per- formed using different regional or anatomic ap- An improperly evaluated Gram’s stain can result in proaches order metformin 500mg, the key to detecting subtle abnormalities is unnecessary antibiotic therapy that is detrimental to to consistently use the same approach (using a physi- an individual bird or to an aviary as a whole cheap 500 mg metformin. A small bird can easily be removed from its enclosure by turning out the lights and gently removing the bird from its perch purchase metformin 500mg otc. A paper or cloth Examination of the Patient towel can be used for removing larger patients from Once a bird’s enclosure has been evaluated for clues their enclosures order metformin with a visa. Paper towels are best for handling that may indicate abnormalities and the bird has birds because they can be discarded after use. If cloth been carefully observed in its environment, it is time towels are used, they should be laundered and auto- to perform a hands-on physical examination. The claved between each bird to prevent nosocomial in- initial consideration in performing a physical exami- fections. A never be used to restrain psittacine or passerine client should be informed that handling a critically ill birds. Tame birds may associate the shape of the bird can destabilize the patient to a point where it glove with discomfort and may equate the hand with can no longer compensate. Removing the top or bottom of an enclosure The examination room used for birds should be se- may be easier than attempting to remove the bird cluded, sealable, easily cleaned, contain minimal fur- through the enclosure door. The towel can be used to niture, have dimmable lights and should not have position the bird so that it is facing the side of the ceiling fans or uncovered windows. With smaller, enclosure in order to have free access to the back of easily stressed species (eg, finches, canaries), per- its head. The best time to grab the bird is when it forming the physical examination in a dimly lighted bites the side of the enclosure. Small birds can be restrained with one hand by Any equipment or supplies that may be needed placing the bird’s head between the second and third should be prepared before a bird is removed from its fingers (Figure 8. The Dermis and its Unique Adaptations The feather condition of a bird is an excellent indication of its overall health. Ear protectors should always be available in the examination (pterylae) and non-feathered areas room and treatment area to prevent the hearing loss that can occur from repeated exposure (apteria) of the body. Genetically induced baldness has been de- able to move the sternum in order to breathe, and scribed in cockatiels. Some incubating hens will de- excessive force on the chest can result in asphyxi- velop a featherless area on the abdomen called a ation. The normal feather brilliance or “sheen” is derived The towel used to initially remove a bird from its from a combination of physical color, structural re- enclosure can remain around the bird at a level even flection of light (structural color), the presence or with the upper eyelid and just below the nares. This absence of powder from the powder down feathers (if gives the bird something to chew on, as well as present) and oil from the preen gland (if present). A large bird bird loses its sheen if abnormalities occur in any of can be cradled on its back between the clinician’s the factors that contribute to the reflectivity of the body and arm. For some clinicians, a complete physi- and evenly from one portion of the feather to another. The skin over most of a bird’s body is thin, soft, dry and relatively translucent (Figure 8. Small portions of discarded feather sheaths are normally found on the skin and should not be confused with dry, flaky skin. Examination of subcutaneous tissues can be enhanced by wetting the overlying feathers with warm water or alcohol (Figure 8. Balding, thinning, swelling, peeling or ul- cerations of the skin or scales of the feet and legs are indications of abnormalities. Chang- ing a bird from a seed-based to a formu- lated diet, supplemented with fresh fruits and vegetables, will generally cause a dra- matic difference in the skin and feather condition. The improvement in the feather quality will be most noticeable with the first molt following the diet change. When a bird is relaxed, the feathers lie flat and follow the natural con- tour of the body. The towel can be the body, and feathers from a damaged wrapped around the bird’s body to provide additional restraint. The bird can be follicle may twist or grow in an abnormal cradled in a sitting position between the clinician’s body and arm, leaving both hands free to palpate body surfaces and to manipulate the feet and wings during direction (see Color 24). Wet, sticky or stained feathers feather shaft (rachis) is smooth and gradually around the nares are indications of rhinitis. General- changes from thin at the tip to thick at the base ized feather abnormalities indicate systemic abnor- (calamus). The contour feathers One of the many functions of feathers is to retain that cover the body should blend with each other, body heat. If chilled, a bird increases its insulation giving the bird a smooth, compact appearance (Color capacity by increasing the distance between the 8. Feathers should be complete and intact feathers and the skin (fluffing up), therefore creating throughout their length and width. Some fluffing can broken or frayed feather edges are indications of a be considered normal in birds that are restricted to problem (see Color 24). A bird that is diseased may Malnutrition in general may cause these kinds of be “fluffed” because it is chilled or because it is con- feather problems. Such birds appear sparsely feath- suming insufficient energy to maintain a proper me- ered, not because the feathers are reduced in number tabolic rate and compensate for normal heat loss. These problems are often characterized by discharges from or enlargement of the feather follicles (see Color 24). Damage that occurs to a feather during development is characterized by an abnormal feather structure or color that is evident as the sheath is removed from the differentiated feather. Dark lines located transversely across sev- eral feathers (stress lines) indicate that an adreno- cortical surge occurred while the affected feather was developing. Post-developmental feather problems are characterized by an abnormal rachis, barb or barbules but a normal follicle and calamus. The fact that avian skin is translucent uneventful with an old feather being forced out by a allows direct visualization of many subcutaneous structures in- cluding vessels, the crop, tendons, ligaments, body musculature, newly developing feather (see Chapter 24). Retention of the feather sheath is not normal, and may indicate mal- nutrition, pansystemic disease or an infectious agent. Damaged pin feathers cut or broken off at the surface may be black and mistaken for mites. Head feathers may appear abnormal in canaries that are malnourished, especially in repro- ductively active hens. The powder down feathers of the prolateral region should be examined for the presence of powder for- mation or feather deformities. Moist lacerations or ulcerations may be noted in the axillary region in some birds with dermatitis (see Color 24). The feathers that are replaced should be cautiously applied to open wounds because the systemic uptake of this product can cause intoxication. The beak, skin and nails in these birds will content or when they wish to be preened or as a part frequently contain accumulations of keratinized epi- of the mating ritual. Head The head should be symmetrical with respect to the Nasal discharges may be unilateral or bilateral and eyes, periorbital areas, cere, beak and nostrils. The may appear clinically as dirty, malpositioned or eyes of a normal bird are clear, bright and centered moist feathers around the nares. The blink response can tis may be accompanied by severe cases of air saccu- be evaluated by lightly touching the canthus. Normal litis, sinusitis and caseous accumulations in the eyelid margins should be symmetrical and smooth. Periorbital swelling usually indi- Scabs, scars or active pustules on the lid margins cates a sinus infection. Signs of previous respiratory may be indicative of poxvirus (particularly in Ama- disorders may include grooves in the beak or loss of zon parrots) (see Color 26). Periophthalmic swelling, epiphora or conjunctivitis all indicate ocular or sinus abnormalities. Conjuncti- The operculum should be well defined in the nasal vitis is most common in cockatiels, lovebirds and cavity. In cockatiels and lovebirds, bacte- cells adjacent to the operculum can create a mass rial, mycoplasmal, chlamydial or viral conjunctivitis that can become secondarily infected with bacteria or may damage the lids resulting in dry eye (see Color fungus, resulting in a unilateral rhinitis accompa- 26). Malnutrition, primary or secondary to giardi- nied by severe tissue necrosis (see Chapters 22 and 41). A common problem in cockatiels is partial lid paralysis, with Pathology in the sinus or nasal cavities may alter the ectropion and conjunctivitis (see Chapter 41).

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Pathology Resident Manual Page 196 • t(8;14) - What disorder(s) is this associated with? Describe how Prader-Willi and Angelman diseases are associated with genomic imprinting? How are ovarian teratomas and partial molar pregnancies related to genomic imprinting? Verify the correct test has been ordered and the correct procedure is being performed buy metformin in united states online. Be ready to discuss the relationship between the diagnosis and the cytogenetic result generic 500 mg metformin with mastercard. Pathology Resident Manual Page 198 • Spend as much time as possible in the Cytogenetics Laboratory (if gone to a conference cheap metformin online visa, leave your page number with a tech) buy discount metformin 500mg line. You will be assigned a desk in the analysis area where you can do your reading and where you can become involved with cases as they arrive and are being analyzed. World Health Organization Classification of Tumors: Pathology & Genetics – Tumors of Haematopoietic and Lymphoid Tissues, Ed. World Health Organization Classification of Tumors: Pathology & Genetics – Tumors of Soft Tissue and Bone, Ed. One month is spent at Children’s Mercy Hospital (three weeks in the molecular diagnostic laboratory and one week in clinical toxicology lab). And two to four days are spent at the Midwest Transplant Network to learn the testing concepts in histocompatibility testing for transplants. Objectives: Learning Evaluation Activities Activities Demonstrate the ability to critically assess the scientific literature. Specific Analytical and Technical Training Learning Objectives for Molecular Pathology • Have awareness of sample types, preparation, and storage for molecular biology tests. Consultation and Presentation of Cases Using Molecular Techniques/Data • Understand and use pedigrees for familial genetic assessments. Recommendations for in-house development and operation of molecular diagnostics tests. Specific Toxicology Learning Objectives: • Be able to answer the following questions: What is the meaning of comprehensive drug screening? What are the most common drugs seen in overdose situations (pediatrics vs adults)? The description of the dermatopathology portion of the rotation is described first followed by the neuropathology portion of the rotation. Sets of glass slides organized by pathogenesis for self-study are available for correlation with the required reading. The resident should assist in the preparation of the weekly dermatopathology conference for the dermatology residents and the monthly dermatopathology conference for the pathology residents. Residents are encouraged to pursue a research project that would lead to publication. Learn the following common epidermal neoplasms and cysts: Actinic keratosis Solar lentigo Seborrheic keratosis Squamous-cell carcinoma Acanthoma (clear cell, large cell, epidermolytic, acantholytic, dyskeratotic) Epidermoid cyst Pilar cyst 2. Learn the following adnexal neoplasms: Basal-cell carcinoma Trichofolliculoma Trichoepithelioma Syringoma Cylindroma Spiradenoma Sebaceous hyperplasia Sebaceous carcinoma 3. Learn the following melanocytic neoplasms Acquired benign melanocytic nevus Congenital benign melanocytic nevus Blue nevus Lentigo maligna (melanoma in situ) Superficial spreading melanoma Nodular melanoma Acral lentiginous melanoma 4. Learn the criteria used to separate benign melanocytic nevus from melanoma Learn how to manage melanocytic neoplasms with ambiguous histopathology Learn some of the arguments for and against dysplastic nevus 5. Learn the following mesenchymal neoplasms: Dermatofibroma Cherry angioma Kaposi sarcoma Angiosarcoma Dermatofibrosarcoma protuberans 6. Learn the following hematopoietic neoplasms: Mycosis fungoides Marginal zone lymphoma Follicle-center cell lymphoma Mastocytosis 7. This rotation is office-based and professional attire rather than "scrubs" are encouraged. The resident should help prepare and attend the weekly 3-5 pm Thursday dermatopathology conference for the dermatology residents. The resident should attend the monthly 1-6 pm Kansas City Dermatological Society meeting. If a case report is chosen, it should be completed prior to the end of the rotation. Pathology Resident Manual Page 209 Neuropathology The major purpose of the neuropathology rotation is to review the gross and microscopic anatomy of the nervous system, introduce major categories of disease that affect the human nervous system, and to acquire elementary dissection and diagnostic skills using both autopsy and surgical material. Required Conferences and Seminars Neuro-Oncology Tumor Board Time/Location: Monday, 5:30 p. Pathology Resident Manual Page 212 Primary audience: Neurosurgeons, neuropathologists, radiation oncologists, neuroradiologists, medical oncologists, neurologists, neurosurgery, radiation oncology, neurology, radiology, and pathology residents. Purpose: Weekly review of new patients with central or peripheral nervous system tumors for preoperative and/or postoperative treatment planning. Primary audience: Pathologists, neurologists, neurophysiology fellows, pathology and neurology residents. Primary audience: Pathologists, neurologists, neurosurgeons, pathology, neurology, and neurosurgery residents, medical students. Purpose: Review of classic or unusual cases from current surgical specimens, including consultation cases. Primary audience: Neurosurgeons, neurologists, neuroradiologists, neuropathologists, neurosurgery and neurology residents. Scholarly Activities and Research During Rotation Research within the Division of Neuropathology is an option that residents may choose for research elective activities. Incorporation of residents into experimental neuropathological work ongoing in the Division or selection of projects in clinically related research, e. Residents will be evaluated on their demonstrated ability to provide useful consultation to the clinical service teams, medical knowledge, application of this knowledge to efficient/quality patient care, and gross and microscopic diagnostic, technical and observational skills. Residents are also evaluated on their interpersonal skills, professional attitudes, reliability, and ethics with members of the teaching faculty, peers, laboratory staff, and clinicians. They are further evaluated on their initiative in fostering quality patient care and use of the medical literature, as it relates to their assigned cases. Their timely completion of assigned interpretive reports is another component of the evaluation. Chapters 27-28, Robbins and Cotran Pathologic Basis of th Disease, 7 Edition, Elsevier Saunders, Philadelphia, 2005. Surgical Pathology of the Nervous System and its Coverings, th 4 ed, Churchill Livingstone, New York, 2002. Diagnostic Pathology of Nervous System Tumours, Churchill Livingstone, London, 2002. Tumors of the Peripheral Nervous System, Armed Forces Institute of Pathology, Washington, D. Tumors of the Pituitary Gland, Armed Forces Institute of Pathology, Washington, D. Practice Guidelines for Autopsy Pathology: Autopsy Procedures for Brain, Spinal Cord, and Neuromuscular System, Arch Pathol Lab Med 119:777–783, 1995. Residents must obtain permission from the appropriate faculty member prior to scheduling the elective. Residents must obtain permission from the appropriate faculty member prior to signing up for the elective. A one month rotation can be designed to teach research skills and allow a resident time to begin a clinically related research project that will be carried forward during the rest of the training program. A goal of the rotation is to encourage pathology residents to participate in a research project that will result in formal presentation at national meetings and publication in peer-reviewed journals. Research rotations must have a focused research project and must follow the below described process for formalizing the rotation. A longer period of research training is available as elective time for those who wish to pursue an academic career. Procedure: Listed below are the required procedures for the Research Rotation • The academic year prior to scheduling a research rotation, the resident should identify a faculty sponsor, have the faculty member sign the attached form stating that they will agree to be the mentor and agree to be responsible for the research activity during the scheduled month. The faculty sponsor must submit the progress report along with the standard evaluation of the resident to the resident education committee. He continued to improve his fund of knowledge and diagnostic skills and received positive comments on performance evaluations.

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The base of the syringe barrel allows for the syringe to be held in place by a clamp (usually made of wood) generic 500 mg metformin free shipping. A piece of filter paper (eg cheap metformin 500mg online, Whatman #2) is cut to the dimensions of the microscope slide and a standard 2 mm paper hole punch is used to create a hole in the center of the filter paper purchase metformin us. Fluid samples having low cellularity require a con- centration procedure for easier examination of the cells cheap metformin 500 mg amex. A simple method is to marginate the cells on a smear made by the conven- tional wedge technique used for making blood films. A drop of the fluid sample is placed on a microscope slide and spread slowly using a spreader slide. Just prior to reaching the end of the smear, the spreader slide is quickly backed slightly into the advancing smear, just before lifting it from the surface of the slide containing the smear. This should produce a slide with the marginated cells concentrated at the end of the film. A simple device that uses gravity to concentrate cells provides cytologic samples of better quality than centrifugation (courtesy of Terry Campbell). The clamp is used to secure the aspirated into the tube using a syringe attached to column to the slide. In cases where allowed to stand undisturbed, the fluid is drawn by material cannot be aspirated for examination, a gravity and absorbed into the filter paper. The cells wash sample can be obtained by infusing a small in the fluid fall onto the surface of the slide where amount of sterile isotonic saline into the crop and they adhere. Once the fluid has drained from the aspirating the fluid back into the tube and syringe. After staining, the cells can be Aspiration of the infraorbital sinus of birds suffering found concentrated in the two millimeter circle cre- from sinusitis can provide diagnostic material for ated by the filter paper and column. One technique of sinus aspiration in psittacine birds samples the large Cytologic evaluation of the ingluvies (crop) can be sinus between the eye and the external nares (Figure performed from samples obtained by aspiration. With the head and body properly restrained, a is indicated in birds showing clinical signs of regur- needle (eg, 22 ga one-inch) is passed through the gitation, vomiting, delayed emptying of the crop or fleshy skin at the commissure of the mouth. A crop aspirate is obtained by needle is directed toward a point midway between inserting a sterile plastic, metal or rubber feeding the eye and external nares, keeping parallel with the tube through the mouth and esophagus into the side of the head. The tube should pass matic bone, which lies between the lower corner of freely and not be forced into the crop. Often the tube is facilitated by extending the head and neck to passage of the needle is improved by keeping the straighten the esophagus. This procedure requires some practice and complete restraint to prevent damage to the globe. A caudally misdirected needle could mouth, directing the needle under the zygomatic result in penetration of the ocular orbit; however, bone and ending in the sinus cavity below the eye more commonly, a misdirected needle results in pene- (Figure 10. It is impor- Collection of synovial fluid by arthrocentesis is an- tant to note that in some species (eg, some passerine other example of sample collection by aspiration. Therefore, a surgery, a needle (22 ga or smaller) attached to a bilateral sinusitis may require bilateral aspirations. The cytologic adequate sample, the anesthetized bird may be held sample is prepared by making direct smears using with the head parallel to the floor and the affected the “squash preparation technique. The sinus is flushed from underneath Wash samples are aspiration techniques in which a with the needle directed up; see Chapter 22). This sinus usually yields collect a cytologic sample from locations that may be a smaller sample volume than the previously de- difficult to sample or that provide a poorly cellular scribed sinus. Tracheal washes are commonly performed in inserting the aspiration needle at a perpendicular birds suspected of having respiratory disease of the angle through the skin just below the eye (Figure trachea, syrinx and bronchi. A soft, smooth-tipped, sterile have been blotted with a clean paper towel to remove plastic or rubber tube or catheter small enough to the excess fluid and blood. It is best to lay the slide pass through the trachea is inserted through the against the tissue surface using the weight of the open glottis taking care not to contaminate the tip in slide to make the imprint. The tube is passed to the level of the the slide, too much force is used and the resulting thoracic inlet near the syrinx. The animal is held Contact smears made from tissues that exfoliate parallel to the floor, and sterile saline (0. One method of immediately re-aspirated to complete the wash sam- improving cellular exfoliation is to scrape the tissue ple. Similar wash techniques can be used to collect to be sampled with a scalpel blade and to make the cytologic samples from the air sacs, ingluvies and contact smear from either the scraped surface or the infraorbital sinus. Using a drop of oil on the scalpel blade may improve the ability to detect mites but will interfere with staining Contact Smears for cytologic evaluation. Imprints should be made Cytologic samples can also be obtained by direct from biopsy of internal organs (eg, liver, spleen and contact between the tissue being sampled and the kidney) using the impression technique. Often referred to as contact smears, Scrapings are commonly performed to collect cells these samples are used to evaluate postmortem tis- from the palpebral conjunctiva, cornea, oral cavity or sues or antemortem tissue biopsies. Samples can be ob- tained either from the tip of the endoscope or by Gram’s stain Gram-positive bacteria. Romanowsky stains (Wright’s and Wright-Giemsa) achieve uniformity of staining on the smear. This stain is not used to These stains are commonly used for peripheral blood films and routine evaluate cells. Mycoplasma colonies resemble chlamy- This is a routine cytologic stain used as a wet preparation on dried dia. This stain is not used to evaluate demonstration of fibrin, lipid droplets, fungal hyphae and other struc- cells. Acid-fast stain This stain is used to identify chlamydia inclusions which stain red This specific stain is used to demonstrate acid-fast positive organisms, against a blue-green cellular background. Acid-fast positive organisms stain red, with non-chlamydia particles staining red with this stain as compared whereas other bacteria stain blue. Gram’s stain This stain is used to detect chlamydia and rickettsia, which appear as This is a microbiologic stain used primarily for the classification of small, bright red, “cocci” intracytoplasmic inclusions. Gram-positive organisms stain deep violet, whereas gram-negative organisms stain red. They can be oval, cuboidal, columnar or polygonal (eg, squamous epi- thelial cells). Epithelial cells typically have an abun- dant cytoplasm, small round-to-oval nuclei and dis- tinct cytoplasmic margins. Fibroblasts are typically spindle- shaped with small nuclei that usually follow the shape of the cell. During the cytologic examination, an assessment of the cells is made by identifying the majority of the cell types, the morphology of the cells and character of the noncellular background. The goal of cytology is to identify the cellular message and classify the cell response into one of the basic cytodiagnostic groups. These groups include inflammation, tissue hyper- plasia or benign neoplasia, malignant neoplasia and normal cellularity. In this goose, several fine-needle aspirates from a soft Inflammation tissue mass associated with a humeral fracture revealed numerous degenerating heterophils and macrophages containing phago- A cytodiagnosis of inflammation is made when an cytized bacteria suggestive of osteomyelitis. There were no pleo- morphic cells, abnormal nuclei or mitotic figures suggestive of a increased number of inflammatory cells is detected neoplasm. The inflammatory cells of client chose surgical removal of the humerus, which was unevent- birds are heterophils, lymphocytes, plasma cells and ful. The presence of feather follicles (arrows) visible on the dis- placed antebrachium should not be confused with intralesional gas macrophages (Figure 10. It should be emphasized that heterophils found in tissues and fluids other than abundant, deeply basophilic cytoplasm; an eccentric, peripheral blood may not appear the same as those mature nucleus; and a prominent perinuclear halo found in hemic tissue. Macrophages are large cells with an abun- matory lesions often degranulate and may resemble dant cytoplasm that may contain small granules, mammalian neutrophils. Heterophils and ment free of microbial toxins even though there may eosinophils may be difficult to differentiate in cy- be a bacterial etiology. Eosinophils of domestic fowl stain peroxidase- Macrophagic inflammation is indicated by the pre- positive and heterophils stain peroxidase-negative dominance of macrophages (greater than 50 percent) with the benzidine or p-phenylenediamine meth- in the inflammatory response. These include avian tubercu- nophils may not behave in the same manner as mam- losis, chlamydiosis, foreign body reaction, mycotic malian eosinophils. Multinu- given the same name, there is an implied similar cleated giant cell formation is often associated with function, but the function of avian eosinophils is macrophagic inflammation.

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