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Service delivery in rehabilitation (inpatient 100mg atenolol with amex, outpatient and community-based 4th week: services) - Zsuzsanna Vekerdy-Nagy M order atenolol 100 mg with amex. Basic principles of therapy approaches in psychiatric rehabilitation - János Kollár Ph cheap atenolol 100mg overnight delivery. D Requirements Course description: The aims of the course are understanding the basic principles of the rehabilitation medicine and a special approach to acute medicine with acknowledging the importance of rehabilitation. Dietary problem handicap, deficiency, disability, participation – the health of people with disabilities concept in different cultures and societies). Lecture: Social aspects of disabilities, characteristic features of groups of people with disabilities, homes of 3rd week: people with disabilities, segregated institutes, Lecture: Communicational problems, basic issues of stigmatization, discrimination, employment, psychology. Target group: foreign and Hungarian students of medicine, students of psychology, pedagogy, social workers, physiotherapists, student of Faculty of Public Health. Announced for students in year: from 3rd year students semester: 1st semester, to 5th year semester: 2nd Coordinator: Janos Kollar, PhD. Signature of Lecture Book Lecture attendance may be followed up by the Department. The lectures of the credit course are listed at the web site of the Department of Physiology (http://phys. Examination At the end of the course a written final assessment will be organized in the form of multiple choice questions. The result of this assessment will determine the verification mark of the credit course using the following conversion table: 0-39. The program is conducted between 3rd and 11th academic weeks of the second semester. Tutor can be any professor of the Department, not only her/his seminar/practical instructor. The applicant should contact the chosen professor and request him/her to undertake the tutorship. Professors of the Department maintain the right to accept or refuse to be the tutor of the applicant. Preconditions for the program: mark three (3) or better in Physiology I, successful closing lab and permission of the Department (arranged by the tutor). In case, the number of applicants is higher than 100, the seminar/practical instructor or the course coordinator can refuse applicants with mark three or better. The name of the students registered to the program is published on the website of Department of Physiology on the 3rd academic week. Two students works in team on one project, and prepare one mutual report, thus they get the same score at the end of the program regardless their contribution. Evaluation of the students is based on the written report or the oral presentation using five grade score system (1-5). The list of offered programs are available at the practical lab of the Department or on the Department’s homepage (http://phys. Appendix or supplementary material, all together no longer than 20 pages, containing data or methodological information can be attached to the manuscript if it is necessary. Easy reading of the text should be considered as primary importance when choosing typeface and font size. Instead of pursuing artistic view, the format of the text should serve the content. Page numbering starts on front page (can be hidden); footnotes and page headings should be used sparingly. The text should be written in good English/American, but prevent using the mixtures of these. Use standard abbreviations where possible, and always give definition at first use. A caption should have a brief title and short description of the illustration with a compact conclusion. All sections should begin on new page, headings typographically separated from the text, centered between left and right margins. Requirements for the sessions: - Front page should contain the followings (template is available at the course coordinator). State the objectives of the work and provide an adequate background, avoiding a detailed literature survey or a summary of the results. Flow-charts, diagrams or photographs to demonstrate critical methodological steps or simplify long descriptions are welcomed. Raw data can be used only as representative recordings or examples if necessary, appropriate use of statistical methods is critical when presenting results. Attempts to resolve contradiction between your own data or your data and the literature is greeted. The reviewers evaluate the manuscripts on a five grade scale according to the following criteria. Numerous stylistic or typographical errors without influencing the readability of the text. Satisfactory is given if illustrations are not clear, graphically not well presented or hard to understand the message. Selected method is appropriate but the manuscript has several substantial flaws in the analysis or the write-up. Inappropriate statistical method, insufficient data or numerous stylistic, typographical errors in text or graphical errors in illustrations results pass too.

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However order atenolol 50mg visa, double-blind studies of the effectiveness of lysine supplementation with uncontrolled avoidance of arginine-rich foods have shown inconsistent results cheap atenolol 100 mg amex. Topical Treatments Lemon Balm One of the most widely used topical preparations in the treatment and prevention of herpes outbreaks is a concentrated extract (70:1) of lemon balm (Melissa officinalis) discount 50 mg atenolol visa. Rather than a single antiviral chemical, lemon balm contains several components that work together to prevent the virus from infecting human cells. When lemon balm cream was used in patients with an initial herpes infection, results from comprehensive trials in three German hospitals and a dermatology clinic demonstrated that there was not a single recurrence. Furthermore, it was noted in these studies that the lemon balm cream produced an interruption of the infection and promoted healing of the herpes blisters much faster than normal. The control group receiving other topical creams had a healing period of 10 days, while the group receiving the cream healed completely within 5 days. Researchers found that if subjects used this cream regularly, they would either stop having recurrences or experience a tremendous reduction in the frequency of recurrences (an average cold-sore-free period of more than 3. Detailed toxicology studies have demonstrated that it is extremely safe and suitable for long-term use. This triterpenoid component of licorice (Glycyrrhiza glabra) root inhibits both the growth and the cell-damaging effects of herpes simplex and other viruses. Support of the immune system is of primary importance, necessitating control of food allergens and optimizing nutrients necessary for cell-mediated immunity. Strengthening the immune system can be effective at reducing the frequency, duration, and severity of recurrences. Diet A diet that avoids major food allergens and limits arginine-rich foods while promoting lysine-rich foods is recommended (refer to the table above). The foods with the worst arginine-to-lysine ratio are chocolate, peanuts, and almonds. In fact, it is generally regarded as the most significant risk factor for a stroke. Individuals with a normal diastolic pressure (under 85 mm Hg) but significantly elevated systolic pressure (over 158 mm Hg) have what is termed isolated systolic hypertension. It is usually an indication of significant hardening of the aorta and carries with it a twofold increase in cardiovascular death rates when compared with a systolic pressure under 130 mm Hg). Dietary factors include excessive calorie consumption; high sodium-to-potassium ratio; low-fiber, high-sugar diet; high consumption of saturated fat and low consumption of omega-3 fatty acids; and a diet low in calcium, magnesium, and vitamin C. Between 40 and 60% of people with high blood pressure are salt-sensitive (as discussed later). Exposure to heavy metals such as lead, mercury, cadmium, and arsenic may also be a significant factor in some patients. The kidneys take the primary role in the elimination of heavy metals, so these metals concentrate there and disrupt the kidneys’ ability to regulate the body’s fluid volume; this disruption results in sodium and water retention. Although studies of blood lead levels have not consistently shown an association with high blood pressure, it is important to point out that blood lead levels reflect primarily acute exposure. The current conventional wisdom among naturopathic physicians is to treat white-coat hypertension as if it were real, as results from recent studies suggest that it is not an innocent phenomenon. Ideally, drug treatment should be used only until the dietary, lifestyle, and supplement strategies take hold. The most important dietary factors include excessive calorie intake; high sodium-to-potassium ratio; low-fiber, high-sugar diet; high consumption of saturated fat and low consumption of essential fatty acids; a diet low in calcium, magnesium, or vitamin C; and excessive alcohol or caffeine intake. In addition to the following discussions, several of these dietary and lifestyle factors are also discussed in the chapter “Heart and Cardiovascular Health,” because the health of the arteries is critical to maintaining normal blood pressure. Relaxation techniques such as deep breathing exercises, biofeedback, transcendental meditation, yoga, progressive muscle relaxation, and hypnosis have all been shown to have some value in lowering blood pressure. One of the most powerful ways to manage stress and have more energy is diaphragmatic breathing. Regular, short sessions of slow and regular diaphragmatic breathing have also been shown to lower blood pressure in several studies. Measurement of the amount of sodium and potassium excreted in the urine indicated that shallow breathing led to the retention of sodium in the body. When used for 15 minutes per day, this device can lead to significant reduction in blood pressure. Patients with borderline and mild hypertension typically can bring blood pressure readings into the normal range with regular exercise. Weight loss can lead to significant improvement in and even complete elimination of the problem; it can also reduce the number of prescription drugs a person needs to take. It contains 3-n-butylphthalide, a compound that has been found to lower blood pressure. In animals, a small amount of this compound lowered blood pressure by 12 to 14% and cholesterol by about 7%. The research was prompted by the father of one of the researchers, who, after eating 1/4 lb of celery per day for one week, observed that his blood pressure had dropped from 158/96 to 118/82. In a meta-analysis of published clinical trials of garlic preparations that included a total of 415 subjects, subjects who were given a dried garlic powder standardized to contain 1. It is also low in cholesterol; high in dietary fiber, potassium, calcium, and magnesium; and moderately high in protein. In the second trial, sodium intake was also quantified at a “higher” intake of 3,300 mg per day, an “intermediate” intake of 2,400 mg per day, and a “lower” intake of 1,500 mg per day. These results are clinically significant and indicate that a sodium intake below 1,500 mg per day can significantly and quickly lower blood pressure.

Marubini E (Istituto di Statistica Medica e Biometria purchase atenolol 100 mg without prescription, Universita degli Studi di Milano effective 50mg atenolol, Milan order atenolol 100mg otc, Italy), Rebora P, Reina G. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Moskva becomes Moscow Wien becomes Vienna Italia becomes Italy Espana becomes Spain Examples for Author Affiliation 7. Homepage with author afliation Title for Homepages (required) General Rules for Title • Reproduce the title of a homepage as closely as possible to the wording on the screen, duplicating capitalization, spacing, punctuation, and special characters when possible • Use a colon followed by a space to separate a title from a subtitle, unless another form of punctuation (such as a question mark, period, or an exclamation point) is already present • Follow non-English titles with a translation when possible; place the translation in square brackets • End a title with a space Specific Rules for Title • Determining the title • Titles containing a Greek letter, chemical formula, or other special character • Titles not in English • Titles in more than one language • Titles ending in punctuation other than a period • No title can be found Box 15. When there is no clear title: • Look for the most prominent (usually the largest) wording on the opening screen • Look at the title bar of the Web browser (generally in the top lef corner) Box 15 continues on next page... Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Societe Francaise de Mycologie Medicale [French Society of Medical Mycology] [Internet]. Occasionally a homepage does not appear to have any title; it simply begins with the text. When this occurs: • Construct a title from the frst few words of the text • Use enough words to make the constructed title meaningful • Place the constructed title in square brackets Examples for Title 8. Homepage with title and publisher the same, with publisher name abbreviated Content Type for Homepages (optional) General Rules for Content Type • Use a content type to tell the user the format of the Internet item being cited • Begin type information with a lef square bracket 1776 Citing Medicine • Enter the words "homepage on the" • End content type with space Specific Rules for Content Type • Titles ending in punctuation other than a period • Titles not in English Box 21. Standard citation to a homepage Edition for Homepages (required) General Rules for Edition • Indicate the edition/version being cited afer the Type of Medium (and Content Type, if present) when a homepage is published in more than one edition or version • Abbreviate common words (see Abbreviation rules for editions below) • Capitalize only the frst word of the edition statement, proper nouns, and proper adjectives • Express numbers representing editions in arabic ordinals. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Examples: ĉ or ç becomes c ⚬ Do not convert numbers or words for numbers to arabic ordinals as is the practice for English language publications. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Examples: ŏ becomes o ū becomes u ⚬ Do not convert numbers or words for numbers to arabic ordinals as is the practice for English language publications. Homepage with an edition or version Editor and other Secondary Authors for Homepages (optional) General Rules for Editor and other Secondary Authors • A secondary author modifes the work of the author. If the same secondary author performs more than one role: • List all of them in the order they are given on the Web site • Separate the roles by "and" Box 30 continues on next page... Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Word for Word for Word for Language Word for Editor Producer Translator Illustrator editeur German redakteur produzent ubersetzer illustrator herausgeber produzentin dolmetscher Italian redattore produttore traduttore disegnatore curatore editore Russian redaktor rezhisser perevodchik konstruktor izdatel Spanish redactor productor traductor ilustrador editor productora Box 32. When a homepage does not clearly state the place of publication of the Web site: • Look at the top, bottom, or sidebar of the frst screen or the bottom of the last screen of the homepage • If it is not in one of these locations, try to obtain it from a link within the site, usually under a "contact us" or similar link • Look in the source code for the homepage if it is displayed by the Web browser • If the place cannot be determined from the site itself: ⚬ Place the name in square brackets if the city can be reasonably inferred. For example, Chicago as the place of publication of a homepage issued by the American Medical Association. Virtual Pediatric Hospital™: a digital library of pediatric information [Internet]. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Jointly published by the University of Alabama School of Law and the Alabama Department of Mental Health & Mental Retardation. Virtual Pediatric Hospital™: a digital library of pediatric information [Internet]. Homepage with geographic qualifer added to place of publication for clarity Web Sites 1791 18. Homepage with unknown place of publication Publisher for Homepages (required) General Rules for Publisher • A publisher is defned as the individual or organization issuing the homepage • Record the name of the publisher as it appears on the homepage or opening screens, using whatever capitalization and punctuation is found there • Abbreviate well-known publisher names with caution to avoid confusion. When a homepage does not clearly state the name of the publisher: • Look at the top, bottom, or sidebar of the frst screen or the bottom of the last screen of the homepage • Look for the name afer a copyright statement, e. Publisher information is required in a citation; distributor information may be included as a note. If you abbreviate a word in one reference in a list of references, abbreviate the same word in all references. Lisbon: Imprensa Medica; • Romanize names in Cyrillic, Greek, Arabic, Hebrew, Korean Sofa (Bulgaria): Sofa Medizina i Fizkultura; • Romanize names or translate names in character-based languages (Chinese, Japanese). Place all translated publisher names in square brackets unless the translation is given on the Web site. Tokyo: Medikaru Rebyusha; Beijing (China): [Chinese Academy of Social Sciences, Population Research Institute]; Taiyuan (China): Shanxi ke xue ji she chu ban she; [Note that the concept of capitalization does not exist in Chinese. Terefore in transliterating Chinese publisher names only the frst word and proper nouns are capitalized. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications. Aarhus (Denmark): Aarhus-Universitetsforlag [Aarhus University Press]; • As an option, you may translate all publisher names not in English. Place all translated publisher names in square brackets unless the translation is given on the Web site. Jointly published by the University of Alabama School of Law and the Alabama Department of Mental Health & Mental Retardation.

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Is it a request for an expert opinion on the management of another practitioner for the purposes of a medical negligence claim? The request should be studied carefully to ascertain what is required and clarification sought where necessary in the case of any ambiguity quality atenolol 100 mg. The fee or at least the basis on which it is to be set should also be agreed in advance of the preparation of the report generic atenolol 50 mg with amex. If necessary purchase atenolol 100mg visa, the appropriate consents should be obtained and issues of confidentiality addressed. A medicolegal re- port may affect an individual’s liberty in a criminal case or compensation in a personal injury or negligence action. A condemnatory report about a profes- sional colleague may cause great distress and a loss of reputation; prosecuting authorities may even rely on it to decide whether to bring homicide charges for murder (“euthanasia”) or manslaughter (by gross negligence). Reports must be fair and balanced; the doctor is not an advocate for a cause but should see his or her role as providing assistance to the lawyers and to the court in their attempt to do justice to the parties. It must always be conisdered that a report may be disclosed in the course of legal proceedings and that the author may be cross-examined about its content, on oath, in court, and in public. A negligently prepared report may lead to proceedings against the author and perhaps even criminal proceedings in exceptional cases. Certainly a civil claim can be brought if a plaintiff’s action is settled on disadvantageous terms as a result of a poorly prepared opinion. The form and content of the report will vary according to circumstances, but it should always be well presented on professional notepaper with relevant dates and details carefully documented in objective terms. Care should be taken to address the questions posed in the letter of instructions from those who commissioned it. If necessary, the report may be submitted in draft before it is finalized, but the doctor must always ensure that the final text represents his or her own professional views and must avoid being persuaded by counsel or solicitors to make amendments with which he or she is not content: it is the 54 Palmer doctor who will have to answer questions in the witness box, and this may be a most harrowing experience if he or she makes claims outside the area of expertise or in any way fails to “come up to proof” (i. In civil proceedings in England and Wales, matters are now governed by the Civil Procedure Rules and by a Code of Practice approved by the head of civil justice. Any practitioner who provides a report in civil proceedings must make a declaration of truth and ensure that his or her report complies with the rules. Additionally, the doctor will encounter the Coroners Court (or the Procurators Fiscal and Sher- iffs in Scotland), which is, exceptionally, inquisitorial and not adversarial in its proceedings. A range of other special courts and tribunals exists, from eccle- siastical courts to social security tribunals; these are not described here. The type of court to which he or she is called is likely to depend on the doctor’s practice, spe- cialty, and seniority. The doctor may be called to give purely factual evidence of the findings when he or she examined a patient, in which case the doctor is simply a professional witness of fact, or to give an opinion on some matter, in which case the doctor is an expert witness. Usually the doctor will receive fair warning that attendance in court is required and he or she may be able to negotiate with those calling him or her concerning suitable dates and times. Many requests to attend court will be made relatively informally, but more commonly a witness summons will be served. A doctor who shows any marked reluctance to attend court may well receive a formal summons, which compels him or her to attend or to face arrest and proceedings for contempt of court if he or she refuses. If the doctor adopts a reasonable and responsible attitude, he or she will usually receive the sympathetic understanding and cooperation of the law- yers and the court in arranging a time to give evidence that least disrupts his or her practice. However, any exhibition of belligerence by the doctor can induce a rigid inflexibility in lawyers and court officials—who always have the ability to “trump” the doctor by the issuance of a summons, so be warned and be reasonable. A doctor will usually be allowed to refer to any notes made contemporaneously to “refresh his memory,” although it is courteous to seek the court’s agreement. Demeanor in Court In the space available, it is not possible to do more than to outline good practice when giving evidence. Court appearances are serious matters; an individual’s liberty may be at risk or large awards of damages and costs may rely on the evidence given. The doctor’s dress and demeanor should be appro- priate to the occasion, and he or she should speak clearly and audibly. As with an oral examination for medical finals or the defense of a writ- ten thesis, listen carefully to the questions posed. Think carefully about the reply before opening your mouth and allowing words to pour forth. Answer the question asked (not the one you would like it to have been) concisely and carefully, and then wait for the next question. There is no need to fill all silences with words; the judge and others will be making notes, and it is wise to keep an eye on the judge’s pen and adjust the speed of your words accordingly. Pauses between questions allow the judge to finish writing or counsel to think up his or her next question. If anything you have said is unclear or more is wanted from you, be assured that you will be asked more questions. Be calm and patient, and never show a loss of temper or control regard- less of how provoking counsel may be. An angry or flustered witness is a gift to any competent and experienced counsel, as is a garrulous or evasive wit- ness. Stay well within your area of skill and expertise, and do not be slow to admit that you do not know the answer. Your frankness will be appreciated, whereas an attempt to bluff or obfuscate or overreach yourself will almost certainly be detrimental to your position. Doctors usually seek consensus and try to avoid confrontation (at least in a clinical setting). They should remember that lawyers thrive on the adversarial process and are out to win their case, not to engage on a search for truth.

The higher the rating cheap 50 mg atenolol with mastercard, the more aggressive your primary prevention strategies will need to be cheap 100mg atenolol. Still trusted 100mg atenolol, researchers have identified about 30 genetic defects that increase the risk for certain cancers. Some of these cancers are rare; they also tend to be types that develop more often in childhood. Age It’s a fact of life: the older you are, the more likely you are to develop cancer. As a result, there are more cells present in the body that possess mutations and that are prone to develop cancer. In the year 2000, more than 60% of new cancer cases and more than 70% of all cancer-related deaths occurred in people over the age of 65. Perhaps the best-known example of cancer with a genetic basis is an inherited mutation in two genes whose function is to suppress the development of breast cancer. A little more than half of women who inherit mutations in these genes will develop breast cancer by age 70. If you have a strong family history of cancer, it’s worthwhile to talk to your doctor about blood tests that can identify genetic mutations. It’s important to understand and weigh the benefits and risks of genetic testing before these tests are done. There is concern that people with abnormal genetic test results will not be able to get life insurance, or coverage may be available only at a much higher cost. From the public health perspective, not enough women at risk would be identified to justify the enormous cost of widespread testing. If you elect to undergo genetic testing and a mutated gene is found, you will need to be more aggressive in your prevention plan and schedule more frequent exams to monitor for early signs of cancer. For example, if a woman has two first-degree relatives (mother, aunt, or sister) who developed breast cancer, her risk for breast cancer is two to five times greater than that of a woman without such a family history. Race Overall, black Americans are more likely to develop cancer than persons of other racial and ethnic groups (see the table below). Compared with other groups, black men are more likely to have cancers of the prostate, colon and rectum, and lung. In fact, black men have at least a 50% higher rate of prostate cancer than any other group. In contrast, breast cancer rates are highest among white women (114 per 100,000) and lowest among Native American women (33. Such factors include education, access to health care, occupation, income, and exposure to harmful substances in the environment. Medical History Sometimes, having one disease can increase your risk for developing another. The presence of any of these conditions requires a more concerted effort to reduce cancer risk. Hormonal Factors Certain cancers, most notably prostate and breast cancer, are affected by hormonal factors. In prostate cancer, the primary hormonal factor is testosterone, while in breast cancer the hormone of concern is estrogen. For more information, see the chapter “Breast Cancer (Prevention),” or the chapter “Prostate Cancer (Prevention). A long and growing list of other environmental factors linked to certain cancers includes pesticides, herbicides, heavy metals, asbestos, solvents, and possibly exposure to electrical power lines. Substantial increases in risk have been demonstrated in occupational settings where workers have been exposed to high concentrations of certain chemicals, metals, and other substances. Certain Medical Treatments Sometimes medical treatment increases the risk of certain cancers. For example, radiation therapy and many chemotherapy drugs carry with them an increased risk for producing new cancers later on. Estrogen and oral contraceptives have been linked to an increased risk of breast cancer. The term iatrogenic refers to diseases that arise inadvertently as a result of medical or surgical treatment. Lifestyle Factors The importance of a healthful lifestyle in cancer prevention cannot be overstated. The key components are avoiding tobacco use and exposure to cigarette smoke; exercising regularly; and avoiding alcohol or drinking only moderate amounts. Smoking The evidence is overwhelming that smoking is the most preventable cause of cancer and premature death in the United States. Lung cancer mortality rates are more than 20 times higher for current male smokers and 12 times higher for current female smokers compared with people who have never smoked. Smoking is also associated with an increased risk for virtually every other cancer and accounts for at least 30% of all cancer deaths. Smoking is also a major cause of heart disease (the leading cause of death in the United States), strokes, chronic bronchitis, and emphysema. Passive smoking—exposure to secondhand smoke—is an important risk for cancer (particularly lung and breast cancer) and is an even greater risk for causing heart disease. People who don’t smoke but who inhale smoke from the environment may be even more susceptible to the free radical damage the chemicals in smoke cause to their heart and arteries, because their bodies just aren’t used to dealing with such a heavy toxic load. One study found that a woman who has never smoked has an estimated 24% greater risk of getting lung cancer if she lives with a smoker. Environmental Protection Agency estimates that passive smoking causes 3,000 lung cancer deaths each year.

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This should produce a slide with the marginated cells concentrated at the end of the film 50 mg atenolol sale. A simple device that uses gravity to concentrate cells provides cytologic samples of better quality than centrifugation (courtesy of Terry Campbell) discount atenolol 100 mg overnight delivery. The clamp is used to secure the aspirated into the tube using a syringe attached to column to the slide cheap 50mg atenolol amex. 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.