By D. Larson. Sierra Nevada College.
Its use is relatively contraindicated where there is an increased risk of regurgitation purchase vytorin now, for example in emergency cases buy vytorin on line, pregnancy and patients with a (b) hiatus hernia vytorin 20 mg free shipping. Eventually cheap vytorin 20 mg visa, resistance will be felt at the point where the tip of the mask lies at the upper oesophageal sphincter (Fig. Tracheal intubation This is the best method of providing and securing a clear airway in patients during anaesthesia and re- (b) suscitation, but success requires abolition of the la- ryngeal reﬂexes. Deep inhalational anaesthe- sia or local anaesthesia of the larynx can also be used, but these are usually reserved for patients where difﬁculty with intubation is anticipated, for example in the presence of airway tumours or im- (c) mobility of the cervical spine. Common indications for tracheal intubation •W here muscle relaxants are used to facilitate sur- gery (e. The equipment used will be determined by the cir- • Catheter mount: or ‘elbow’ to connect the tube to cumstances and by the preferences of the indivi- the anaesthetic system or ventilator tubing. The following is a list of the basic • Suction: switched on and immediately to hand in needs for adult oral intubation. The technique of oral intubation The cuff is inﬂated by injecting air via a pilot tube, at the distal end of which is a one-way valve to pre- Preoxygenation vent deﬂation and a small ‘balloon’ to indicate when the cuff is inﬂated. A wide variety of All patients who are to be intubated are asked to specialized tubes have been developed, examples breathe 100% oxygen via a close-ﬁtting facemask of which are shown in Fig. This provides a • Reinforced tubes are used to prevent kinking and reservoir of oxygen in the patient’s lungs, reducing subsequent obstruction as a result of the position- the risk of hypoxia if difﬁculty is encountered with ing of the patient’s head (Fig. Once this has been accomplished, the • Preformed tubes are used during surgery on the appropriate drugs will be administered to render head and neck, and are designed to take the con- the patient unconscious and abolish laryngeal nections away from the surgical ﬁeld (Fig. Positioning Intubation The patient’s head is placed on a small pillow with The tracheal tube is introduced into the right side the neck ﬂexed and the head extended at the of the mouth, advanced and seen to pass through the atlanto-occipital joint, the ‘snifﬁng the morning cords until the cuff lies just below the cords. The patient’s mouth is fully opened tube is then held ﬁrmly and the laryngoscope is using the index ﬁnger and thumb of the right hand carefully removed, and the cuff is inﬂated sufﬁ- in a scissor action. Laryngoscopy For nasotracheal intubation a well-lubricated The laryngoscope is held in the left hand and the tube is introduced, usually via the right nostril blade introduced into the mouth along the right- along the ﬂoor of the nose with the bevel pointing hand side of the tongue, displacing it to the left. It is ad- The blade is advanced until the tip lies in the gap vanced into the oropharynx, where it is usually between the base of the tongue and the epiglottis, visualized using a laryngoscope in the manner de- the vallecula. The rectly into the larynx by pushing on the proximal effort comes from the upper arm not the wrist, to end, or the tip picked up with Magill’s forceps lift the tongue and epiglottis to expose the larynx, (which are designed not to impair the view of the seen as a triangular opening with the apex anteri- larynx) and directed into the larynx. The proce- orly and the whitish coloured true cords laterally dure then continues as for oral intubation. It is inserted by holding the handle rather Due to: than using one’s index ﬁnger as a guide, and sits • Unrecognized oesophageal intubation If there is opposite the laryngeal opening. A specially de- any doubt about the position of the tube it should signed reinforced, cuffed, tracheal tube can then be be removed and the patient ventilated via a inserted, and, due to the shape and position of the facemask. Conﬁrming the position of the • Aspiration Regurgitated gastric contents can tracheal tube cause blockage of the airways directly, or secondary This can be achieved using a number of to laryngeal spasm and bronchospasm. Cricoid techniques: pressure can be used to reduce the risk of regurgita- • Measuring the carbon dioxide in expired gas (capnog- tion prior to intubation (see below). Trauma • Oesophageal detector: a 50mL syringe is attached to the tracheal tube and the plunger rapidly with- • Direct During laryngoscopy and insertion of the drawn. If the tracheal tube is in the oesophagus, re- tube, damage to lips, teeth, tongue, pharynx, lar- sistance is felt and air cannot be aspirated; if it is in ynx, trachea, and nose and nasopharynx during the trachea, air is easily aspirated. Complications of tracheal intubation • Vomiting This may be stimulated when laryn- The following complications are the more com- goscopy is attempted in patients who are inade- mon ones, not an attempt to cover all occurrences. It is more frequent when there is material in the stomach; for example in emergencies when the patient is not starved, in 25 Chapter 2 Anaesthesia patients with intestinal obstruction, or when gas- Cricoid pressure (Sellick’s manoeuvre) tric emptying is delayed, as after opiate analgesics or following trauma. Regurgitation and aspiration of gastric contents are • Laryngeal spasm Reﬂex adduction of the vocal life-threatening complications of anaesthesia and cords as a result of stimulation of the epiglottis or every effort must be made to minimize the risk. Preoperatively, patients are starved to reduce gas- tric volume and drugs may be given to increase pH. At induction of anaesthesia, cricoid pressure pro- Difﬁcult intubation vides a physical barrier to regurgitation. As the Occasionally, intubation of the trachea is made cricoid cartilage is the only complete ring of carti- difﬁcult because of an inability to visualize the lage in the larynx, pressure on it, anteroposteriorly, larynx. This may have been predicted at the forces the whole ring posteriorly, compressing the preoperative assessment or may be unexpected. A oesophagus against the body of the sixth cervical variety of techniques have been described to help vertebra, thereby preventing regurgitation. An as- solve this problem and include the following: sistant, using the thumb and index ﬁnger, applies •M anipulation of the thyroid cartilage by back- pressure whilst the other hand is behind the pa- wards and upwards pressure by an assistant to try tient’s neck to stabilize it (Fig. Pressure is and bring the larynx or its posterior aspect into applied as the patient loses consciousness and view. It long, is inserted blindly into the trachea, over should be maintained even if the patient starts to which the tracheal tube is ‘railroaded’ into place. If trachea via the mouth or nose, and is used as a vomiting does occur, the patient should be turned guide over which a tube can be passed into the tra- onto his or her side to minimize aspiration. Consciousness is lost rapidly as sort to one of the emergency techniques described the concentration of the drug in the brain rises below. The drug is then redistributed to other tissues and the plasma concentration falls; this is followed by a fall in brain concentration and Emergency airway techniques the patient recovers consciousness. Despite a short These must only be used when all other techniques duration of action, complete elimination, usually have failed to maintain oxygenation. Consequently, brane is identiﬁed and punctured using a large bore most drugs are not given repeatedly to maintain cannula (12–14 gauge) attached to a syringe. Currently, the only exception to this ration of air conﬁrms that the tip of the cannula is propofol (see below). The cannula is then angled the dose required to induce anaesthesia will be to about 45° caudally and advanced off the needle dramatically reduced in those patients who into the trachea (Fig. A high-ﬂow oxygen sup- are elderly, frail, have compromise of their ply is then attached to the cannula and insufﬂated cardiovascular system or are hypovolaemic. Breathing an inhalational anaesthetic in oxygen or • Surgical cricothyroidotomy This involves making in a mixture of oxygen and nitrous oxide can be an incision through the cricothyroid membrane to used to induce anaesthesia. However, is assessed (and overdose avoided) using clinical once a tube has been inserted the patient can be signs or ‘stages of anaesthesia’; the original ventilated, ensuring oxygenation, elimination of description was based on using ether, but the main carbon dioxide and suction of the airway to re- features can still be seen using modern drugs. Currently, sevoﬂurane is the most popular anaesthetic used for Drugs used during general this technique. As well as the above, the anaesthetic will have ef- The stages of anaesthesia fects on all of the other body systems, which will need appropriate monitoring. The pupils Maintenance of anaesthesia will be normal in size and reactive, muscle tone is normal and breathing uses intercostal mus- This can be achieved either by using one of a vari- cles and the diaphragm. Second stage In this period there may be breath-holding, Inhalational anaesthesia struggling and coughing. The pupils will be di- Inhalational anaesthetics are a group of halogena- lated and there is loss of the eyelash reﬂex. There is inspired concentration of all of these compounds reduction in respiratory activity, with progres- is expressed as the percentage by volume. The pupils There are two concepts that will help in under- start by being slightly constricted and gradually standing the use of inhalational anaesthetics: dilate. This is the concentration required to prevent 29 Chapter 2 Anaesthesia 30 Anaesthesia Chapter 2 31 Chapter 2 Anaesthesia Table 2. It is the partial pressure in the brain that is responsible for the anaesthetic ef- Nitrous oxide (N2O) is a colourless, sweet-smelling, fect and this follows closely the partial pressure in non-irritant gas with moderate analgesic proper- the alveoli. As pressure can be changed determines the rate of the maximum safe concentration that can be ad- change in brain partial pressure, and hence speed ministered without the risk of hypoxia is approxi- of induction, change in depth of, and recovery mately 70%, unconsciousness or anaesthesia from anaesthesia. Con- One of the main determinants of alveolar partial sequently, it is usually given in conjunction with pressure is how soluble the inhalational anaesthe- one of the other vapours. Decreases the ventila- Recovery from anaesthesia follows similar princi- tory response to carbon dioxide and hypoxia. The length of exposure necessary tained to prevent awareness and any response to may be as short as a few hours, and recovery surgery. This nitrous oxide into the alveoli dilutes any oxygen method can be used for short procedures, but for present (diffusion hypoxia). This can be over- mon to use a microprocessor-controlled infusion come by increasing the inspired oxygen concentra- pump (e. Hav- Halothane hepatitis ing entered the appropriate data, on starting the The precise link between the use of halothane and pump an initial rapid infusion is given to render the subsequent development of hepatitis remains the patient unconscious, followed by an infusion unclear.
These are- Natural inhabitants such as acidophilic bacillus discount vytorin 30 mg free shipping, trepanoma microdentium order 20mg vytorin visa, diplococci order vytorin 20 mg with mastercard, streptococcus salvarius discount 30 mg vytorin overnight delivery, entoameba gingivalis act and those which are in the environment ingested together with food, water and air. It has an optimal temperature, a sufficient amount of food substances and has a weakly alkaline reaction. Frequency of cleaning of the oral cavity Great amount of microbes are found at the neck of teeth and in the space between teeth (interdental space). There are many microbes in other parts of the oral cavity which are in accessible to the bathing action of saliva and the action of lysozyme. The presence of carious teeth is a condition for increasing the micro flora in the oral cavity, for the appearance of decaying process and unpleasant odors. See the children eat balanced diet which reduces the desire to eat sweat, sticky or soft foods between meals. Remove food particles from the mouth after meals and especially last things at night by means of a tooth brush and tooth pastes or local sticks stimulate and harden the gum by a correct brushing and massage. Finish the meal with a hard naturally cleaning food such as an apple carrot or rinse the mouth vigorously with water when tooth brushing is not possible 124 4. Home care of the child It is important to stress the necessity of cleaning of the teeth after every meal, or snack and before going to bed. Eating detensive food stuffs Tooth brushing Tooth brush for children: 6 inches long –Handle 1 and 1/2 inches- Head with several tuffs (filaments). Start from the upper left buccal region then to labial surface of the anterior teeth then to the right buccal region -Æ then to the lingual and palatal of the anterior teeth. Then down to the lower left buccal surface of the posterior teeth, then to the labial surface of anterior 126 teeth, then to the labial surface of the right lower posterior teeth, then to the lingual aspect of the anterior and posterior teeth. Attention should be given to the interdental (proximal spaces) which are favorable place for food impaction. Tooth pastes Purpose: Removes fermentable carbohydrates from tooth Interferes with bacterial activities on the carbohydrates. Other food stuffs such as carrots, sliced oranges are more efficient than tooth brushing in removing yeasts from the mouth after ingestion of a yeast cakes. Prevention of periodontal diseases Normal gum is pink, firm, stippled with well formed papilla and gingival crevices, shallow in depth with out exudates. This topic has been always under discussion with the students who had taken this course and finally we used to agree on one point that is to preach the people to use the local stick (Mefakia) properly as it is not costly and easily available almost to everybody. A study was made in 1978 by Bent Olson in Arussi province on oral health and the study has confirmed that the local stick ( Mefakia) is as effective as tooth brush if it is used properly in all the surfaces of the tooth. Rustovaya texts of Surgical Stomatology for medical students of faculty of stotmatolgy ( In Russian language), 1990 14. Benit Olson, Periodontal disease and Oral hygiene in Arussi province, Ethiopia 1978, studies on dental in Ethiopia, 132 16. The objective of this paper is to review the evidence for an association between nutrition, diet and dental diseases and to present dietary recommendations for their prevention. Nutrition affects the teeth during development and malnutrition may exacerbate periodontal and oral infectious diseases. However, the most signiﬁcant effect of nutrition on teeth is the local action of diet in the mouth on the development of dental caries and enamel erosion. Dental erosion is increasing and is associated with dietary acids, a major source of which is soft drinks. Despite improved trends in levels of dental caries in developed countries, dental caries remains prevalent and is increasing in some developing countries undergoing nutrition transition. There is convincing evidence, collectively from human intervention studies, epidemiological studies, animal studies and experimental studies, for an association between the amount and frequency of free sugars intake and dental caries. Although other fermentable carbohydrates may not be totally blameless, epidemiological studies show that consumption of starchy staple foods and fresh fruit are associated with low levels of dental caries. Fluoride reduces caries risk but has not eliminated dental caries and many countries do not have adequate exposure to ﬂuoride. It is important that countries with a low intake of free sugars do not increase intake, as the available evidence shows that when free sugars consumption is ,15–20 kg/yr (,6–10% energy intake), dental caries is low. For countries with high consumption levels it is recommended that national health authorities and decision-makers formulate country-speciﬁc and community-speciﬁc goals for reducing the amount of free sugars aiming towards the recommended maximum of no more than 10% of Keywords energy intake. In addition, the frequency of consumption of foods containing free Dental diseases sugars should be limited to a maximum of 4 times per day. It is the responsibility of Dietary sugars national authorities to ensure implementation of feasible ﬂuoride programmes for Fluoride their country. Diet also plays a signiﬁcant The burden of dental diseases aetiological role in dental erosion, the prevalence of which Dental diseases are a costly burden to health care services. However, in modern societies, diet costs between 5 and 10% of total health care expenditures and nutrition play a relatively minor role in the aetiology of in industrialised countries exceeding the cost of treating periodontal disease (gum disease), another cause of tooth 1 cardiovascular disease, cancer and osteoporosis. This review will mainly focus on the major developing low-income countries, the prevalence rate of dental diseases, dental caries and dental erosion. Diseases dental caries is high and more than 90% of caries is of the oral mucosa, will not be reviewed in depth, as the untreated. The permanent dentition replaces the in the permanent teeth is generally low and mostly limited deciduous dentition from the age of 6 years and is 6 to the occlusal and buccal/lingual surfaces. In low-income countries, the cost of traditional developed countries, there is a trend for older adults restorative treatment of dental disease is disproportio- now to retain their teeth for longer, however, if the gums nately expensive in light of the low public health priority recede with age the roots of the teeth become exposed, and it would exceed the available resources for health and, being relatively less mineralised than the tooth 7 care. The large ﬁnancial beneﬁts of preventing dental crowns, are susceptible to decay known as ‘root caries’. Teeth are important in enabling consumption of a atrophy which subsequently reduces the mouth’s defence varied diet and in preparing the food for digestion. Teeth vitamins, zinc and iron, can inﬂuence the amount and also play an important role in speech and communication. Undernutrition coupled with adults reported impaired social functioning due to oral daily increased amount and/or frequency of sugars results disease, such as avoiding laughing or smiling due to poor in levels of caries greater than expected for the level of perceived appearance of teeth. In addition, dental formed by bacteria in dental plaque through the anaerobic 8 17 diseases cause considerable pain and anxiety. When sugars factors are likely to be exacerbated in less developed or other fermentable carbohydrates are ingested, the societies where pain control and treatment are not readily resulting fall in dental plaque pH caused by organic acids available. For example, in Thailand, half the children of age increases the solubility of calcium hydroxyapatite in the 12 claimed pain or discomfort from teeth within the past dental hard tissues and demineralisation occurs as calcium 3 is lost from the tooth surface. Similar patterns are observed in other demineralisation occurs is often referred to as the critical 9 10 11 pH and is approximately 5. Saliva is super-saturated with calcium and 12,13 phosphate at pH 7; this favours the deposition of calcium. Tooth loss may, therefore, impede the achievement of dietary goals related to the that cause demineralisation. Tooth loss has remains high enough for sufﬁcient time then complete also been associated with loss of enjoyment of food and remineralisation of enamel may occur. It is, therefore, clear that dental diseases have a detrimental effect on quality of life both in and the enamel becomes more porous until ﬁnally a 18 childhood and older age. The rate of demineralisation is Diet, nutrition and prevention of dental diseases 203 affected by the concentration of hydrogen and ﬂuoride there is little evidence for an association between diet and ions (i. Fluoride inhibits the periodontal disease, although current interest is focusing demineralisation process and the frequency with which on the potential preventive role of antioxidant nutrients. So overall, caries occurs disease is the presence of plaque, and prevention when demineralisation exceeds remineralisation. There is some evidence that ﬂuoride promotes remineralisation will be discussed to suggest that periodontal disease progresses more later. Overgrowth of the bacterial proﬁle, quantity and quality of the saliva, and periodontopathic organisms and yeasts has been observed 23,24 the time for which fermentable dietary carbohydrates are in malnourished African children. Streptococcus mutans intake is associated with increased plaque volume due to and Streptococcus sorbrinus are important bacteria in the the production of extracellular glucans, and there is a development of dental caries. The role of invertase splits sucrose into glucose and fructose, which dietary practices in the prevention of periodontal disease can be metabolised to produce mainly lactic but also other will not be discussed further. A low pH in plaque is ideal Nutrition and oral infectious diseases for aciduric bacteria such as streptococci, lactobacilli and Malnutrition consistently impairs innate and adaptive biﬁdobacteria as these are more competitive at low pH defences of the host, including phagocytic function, cell- than bacteria not associated with dental caries. Cellular often associated with other forms of tooth wear such as depletion of antioxidant nutrients promotes immunosup- abrasion and attrition (from over zealous oral hygiene and pression, accelerated replication rate of ribonucleic acid grinding of teeth, for example). Low salivary ﬂow rate infections and may lead to their evolution into life- or inadequate buffering capacity are factors that exacer- threatening diseases. Among the suspected causative factors are increased oral citric acid, phosphoric acid, ascorbic acid, malic acid, burden of free glucocorticoids and impaired host defence tartaric acid and carbonic acids found in fruits and fruit of saliva. No inﬂammatory oral lesions underscore the juices, soft drinks—both carbonated and still, some herbal association between malnutrition and oral health as teas, dry wines and vinegar-containing foods.
In over 95% of patients there is a replacement of normal bone marrow by cells with an abnormal chromosome- the Philadelphia or Ph chromosome purchase 20mg vytorin with visa. This is an abnormal chromosome 22 due to the translocation of part of a long (q) arm of chromosome 22 to another chromosome buy cheap vytorin 20 mg on line, usually 9 purchase vytorin 30 mg fast delivery, with translocation of part of chromosome 9 to chromosome 22 purchase vytorin 20 mg fast delivery. It is an acquired abnormality of hemopoietic stem cells that is present in all dividing granulocytic, erythyroid and megakaryocytic cells in the marrow and also in some B and probably a minority of T lymphocytes. In at least 70% of patients there is a terminal metamorphosis to 308 Hematology acute leukemia (myeloblastic or lymphoblastic) with an increase of blast cells n the marrow to 50% or more. It most cases there are no predisposing factors but the incidence was increased n survivors of the atom bomb exposures in Japan. The accumulation of large numbers of lymphocytes to 50-100 times the normal lymphoid mass in the blood, bone marrow, spleen, lymph nodes and liver may be related to immunological non-reactivity and excessive lifespan. It is an unusual disease of peak age 40-60 years and men are affected nearly four times as frequently as women. The is a monoclonal proliferation of cells with an irregular cytoplasmic outline (‘hairy’ cells, a type of B lymphocyte) in the peripheral blood, bone marrow, liver and other organs. The bone marrow trephine shows a characteristic appearance of mild fibrosis and a diffuse cellular infiltrate. There is a tendency to progress to acute myeloid leukemia, although death often occurs before this develops. Malignant Lymphomas 314 Hematology This group of diseases is divided into Hodgkin’s disease and non-Hodgkin’s lymphomas. In many patients, the disease is localized initially to a single peripheral lymph node region and its subsequent progression is by contiguity within the lymphatic system. After a variable period of containment within the lymph nodes, 315 Hematology the natural progression of the disease is to disseminate to involve non-lymphatic tissue. It has bimodal age incidence, one peak in young adults (age 20-30 years) and a second after the age of 50. In developed counties the ratio of young adults to child cases and of nodular sclerosing disease to other types is increased. Tuberculosis may occur • Patients with bone disease may show hypercalcaemia, hypophosphataemia and increased levels of serum alkaline phosphatase. Laboratory findings • A Normochromic, normocytic anemia is usual but auto-immune hemolytic anemia may also occur. Multiple Myeloma Multiple myeloma (myelomatosis) is a neoplastic monoclonal proliferation of bone marrow plasma cells, characterized by lytic bone lesions, plasma cell accumulation in the bone marrow, and the presence of monoclonal protein in the serum and urine. Immunological testing shows these cells to be monoclonal B cells and to express the same 319 Hematology immunoglobulin heavy and light chains as the serum monoclonal protein. These disorders are closely related to each other; transitional forms occur and, in many patients, an evolution from one entity into another occurs during the course of the disease. Polycythemia vera Polycythemia (erythrocytosis) refers to a pattern of blood cell changes that includes an increase in hemoglobin above 17. In polycythemia vera (polycythemia rubra vera), the increase in red cell volume is caused by endogenous myeloproliferation. The stem cell origin of the defect is suggested in many patients by an over production of granulocytes and platelets as well as of red cells. Clonal cytogenetic abnormalities may occur, but there is no single characteristic change • Blood viscosity is increased • Plasma urate is often increased • Circulating erythroid progenitors are increased and grow in vitro independently of added erythropoietin. Essential thrombocythemia Megakaryocyte proliferation and overproduction of platelets is the dominant feature of this condition; there is sustained increase in platelet count above normal (400x109/l). Splenic enlargement is frequent in the early phase but splenic atrophy due to platelets blocking the splenic mirocirculation is seen in some patients. Laboratory findings • Abnormal large platelets and megakaryocyte fragments may be seen in the blood film. Myelofibrosis Myelofibrosis, one of the myeloproliferative diseases, is the gradual replacement of the bone marrow by connective tissue. Patients will typically have an enlarged spleen and liver, (hepatosplenomegaly), and examination of the blood cells will show "teardrop cells". There is an increase in circulating stem cells associated with the establishment of extramedullary hemopoiesis. Laboratory findings • Anemia is usual but a normal or increased hemoglobin level may be fond in some patients • The white cell and platelet counts are frequently high at the time of presentation. Trephine biopsy may show a hypercellular marrow with an increase in reticulin-fibre pattern; in other patients there is an increase in intercellular substance and variable collagen deposition. Introduction Leucocyte cytochemistry encompasses the techniques used to identify diagnostically useful enzymes or other substances in the cytoplasm of hemopoietic cells. These techniques are particularly useful for the characterization of immature cells in the acute myeloid leukemias, and the identification of maturation 328 Hematology abnormalities in the myeloproliferative disorders. The use of cytochemistry to characterize lymphoproliferative disorders has been largely superseded by immunological techniques. The results of cytochemical tests should always be interpreted in relation to Romanowsky stains and immunological techniques. Control blood or marrow slides should always be stained in parallel to assure the quality of the staining. The principal uses of cytochemistry are: • To characterize the blast cells in acute leukemias as myeloid. Staining can be enhanced by immersing the slides in copper sulphate or nitrate, but this is generally not required in normal diagnostic practice. The most primitive myeloblasts are negative, with granularly positively appearing progressively as they mature towards the promyelocyte stage. Promyelocytes and myelocytes are the most strongly staining cells in the granulocyte series, with positive (primary) granules packing the cytoplasm. Eosinophil granules stain strongly, and the large specific eosinophil granules are easily distinguished from neutrophil granules. Eosinophil granule peroxidase is distinct biochemically and immunologically from neutrophil peroxidase. When positive, the granules are smaller than in neutrophils and diffusely scattered throughout the cytoplasm. Sudan Black B 331 Hematology Sudan black B is a lipophilic dye that binds irreversibly to an undefined granule component in granulocytes, eosinophils and some monocytes. The only notable difference is in eosinophil granules, which have a clear core when stained with Sudan black B. Basophiles are generally not positive, but may show bright red/purple metachromatic staining of the granules. Although demonstrated as a granular reaction product in the cytoplasm, enzyme activity is associated with a poorly characterized intracytoplasmic membranous component distinct from primary or secondary granules. Other leucocytes are generally negative, but rare cases of lymphoid malignancies show cytochemically demonstrable activity. Early methods of demonstrating alkaline phosphatase relied on the use of glycerophosphate or other phosphomonoesters as the substrate at alkaline pH, with a final black reaction product of lea sulphide. These methods use substituted naphthols as the substrate, and it is the liberated naphthol rather than phosphate that is utilized to combine with the azo-dye to give the final reaction product. The intensity of reaction product in neutrophils varies from negative to strongly positive, with coarse granules filling the cytoplasm and overlying the nucleus. An overall score is obtained by assessing the stain intensity in 100 333 Hematology consecutive neutrophils, with each neutrophil scored on a scale of 1-4 as follows: 0 Negative, no granules 1 Occasional granules scattered in the cytoplasm 2 Moderate numbers of granules 3 Numerous granules 4 Heavy positively with numerous coarse granules crowding the cytoplasm, frequently overlying the nucleus The overall possible score will range between 0 and 400. Reported normal ranges show some variations, owing possibly in part to variations in scoring criteria and methodology. Published normal ranges illustrate the need for establishing a normal range in any one laboratory: Hayhoe & Quaglino = 14-100 (mean 46); Kaplow = 13 -160 (mean 61); Rutenberg et al=37-98 (mean 68); Bendix-Hansen & Helleberg-Rasmussen=11-134 (mean 48) The scoring system described by Bendix-Hansen & Helleberg-Rasmussen differs slightly in emphasis from the others, but gives similar results. Newborn babies, children and pregnant women have high scores, and premenopausal women have, on average, scores one-third higher than men. Acid Phosphatase Reaction Cytochemically demonstrable acid phosphates is 335 Hematology ubiquitous in hemopoietic cells. The pararosaniline method given below, modified from Goldberg & Barka, is recommended for demonstrating positively in T lymphoid cells.