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By: Richard N Mitchell, MD, PhD

  • Lawrence J. Henderson Professor of Pathology and Health Sciences and Technology, Department of Pathology, Harvard Medical School, Staff Pathologist, Brigham and Women's Hospital, Boston, Massachusetts

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Chemotherapy has limited utility in malignant gliomas gastritis medication list cheap 20 mg pariet with mastercard, although oligodendrogliomas are highly chemosensitive (associated with chromosome 1p and 19q loss) gastritis diet ужасы discount pariet online amex. For patients with multiple brain metastases gastritis diet дром order 20mg pariet with mastercard, whole brain radiotherapy is the treatment of choice gastritis symptoms heartburn purchase generic pariet on line. Stereotactic radiosurgery or gamma-knife radiotherapy may be considered for those with solitary or few metastases. Brain metastases usually respond poorly to systemic chemotherapy due to poor penetration of chemotherapy through the blood-brain barrier. Immunohistochemical stains or electron microscopy may reveal the likely tissue of origin. Young men with poorly differentiated carcinoma and mediastinal or retroperitoneal mass: Treat as germ cell tumor patients; evaluate for occult testicular cancer. Chemotherapy regimen for patients not falling into the above categories: Etoposide and a platinum (cisplatin or carboplatin). Bone marrow aspirate and biopsy to assess for blasts, to include immunohistochemistry, cytogenetic evaluation, and flow cytometry. Consolidation therapy using high-dose Ara-C may lead to durable remission or cure. Bone marrow transplant (allogeneic or autologous) is considered in patients who relapse or who have cytogenetic changes that put them at high risk for recurrence. Retinoic acid syndrome: Characterized by pulmonary infiltrates, respiratory failure, fever, capillary leak syndrome, and cardiovascular collapse. Accelerated phase: Signaled by the presence of blasts and early forms in the peripheral blood; represents a transition to more aggressive disease. Highly refractory to conventional therapy; most often symptomatic (night sweats, weight loss, bone pain, fevers, cytopenias). Treatment has changed dramatically since the introduction of imatinib (see below). Busulfan and hydroxyurea play a role in reducing blood counts but are palliative and not curative. More than 90% of patients in the chronic phase will have complete normalization of blood counts (morphologic or hematologic remission) and 65% will have normal cytogenetics after one year of imatinib therapy (cytogenetic remission). Only 10% of patients in blast phase have complete hematologic remission; 15% have major cytogenetic response. Many different treatment approaches are available, including alkylating agents (chlorambucil, cyclophosphamide), nucleoside analogs (fludarabine, cladribine, pentostatin), and monoclonal antibodies (alemtuzumab). Refractory disease: Patients with refractory disease should be considered for high-dose chemotherapy followed by autologous stem cell transplant. High grade: Highly aggressive and rapidly growing cancers, but potentially curable with chemotherapy. Mantle cell lymphoma: Acts like an intermediate-grade lymphoma in aggressiveness but is not curable with conventional chemotherapy (as with low-grade lymphoma). The International Prognostic Index predicts outcomes on the basis of pretreatment patient characteristics. Acute promyelocytic leukemia: t(15;17) retinoic acid receptor and promyelocytic leukemia gene. Delayed emesis: Begins after 24 hours (associated with cisplatin, carboplatin, or cyclophosphamide). Anticipatory emesis: A conditioned response in patients who have had poor nausea control with previous treatments. There is no indication for giving myeloid growth factors with uncomplicated neutropenic fever. Appetite stimulants: Dronabinol, cyproheptadine, corticosteroids, megestrol acetate. Fatigue Usually multifactorial and includes anorexia, anemia, depression, infection, hypoxia, deconditioning, and hypogonadism. Management: Anemia is often a contributing factor; treat with transfusions or erythropoietic growth factors in chemotherapy treated patients. Corticosteroids, megestrol acetate, counseling, physical therapy, and exercise may all help in selected patients. As with other illness, symptoms suggest categories that can then be further clarified. In general, there are no objective laboratory tests for psychiatric diagnostic clarification, so a careful history is essential. Some psychiatric syndromes are diagnoses of exclusion; therefore, likely medical etiologies must be ruled out before such diagnoses can be made. Psychotic disorders are treated with antipsychotics; anxiety disorders are treated with anxiolytic agents. Mood disorders are treated with antidepressants or mood stabilizers, depending on unipolarity or bipolarity. For these syndromes, treatment generally involves medication with > 1 category, targeting each symptom separately. The choice of medication in each class should be based on several factors: Proven efficacy for the illness being treated. The choice of benzodiazepine to use should be based on the nature of the anxiety symptom being treated (see Figure 15. Psychiatric: Generalized anxiety disorder: Patients typically have more chronic baseline anxiety. Panic disorder can occur with or without agoraphobia (fear of open spaces or of being alone in a crowd or leaving the home). A 42-year-old man with mild psychomotor agitation complains that for the past six months, "my nerves have been shot. The patient also has chronic neck and shoulder tension as well as mild daily headaches that are relieved by acetaminophen. The woman, previously demure and shy, frequently stands up to admire the artwork in your office, which she describes as "unusually sensual; I might have to test your kissing ability some day. On interview, the man seldom speaks unless asked a question and rarely makes eye contact except to ask you if his eyes look okay, "because I see colors too brightly now. When asked why he left college, the man states that "no one there can handle the truth-the truth of the elders of the dean and his spies. Generalized Anxiety Disorder Defined as uncontrollable worry about a broad range of topics. Major depressive disorder: Patients usually have depressed mood and other physical symptoms. Generalized anxiety disorder: Patients have chronic baseline anxiety about many things, not just when they are exposed to a trigger. Patients must recognize that their symptoms are unreasonable and that their obsessions are their own thoughts. Schizophrenia: Patients have psychotic symptoms along with affective flattening, asociality, and avolition. Generalized anxiety disorder: Patients have anxiety in several different areas of their lives that are generally not relieved by compulsive acts. Behavioral: Exposure-response prevention therapy; cognitive-behavioral therapy (teaches patients how to diminish their cognitive distortions of the stressor and how to change their behavioral response). Generalized anxiety disorder: Patients do not have a history of a traumatic event or flashbacks. Substance-induced mood disorder: Illicit drugs, thiazide diuretics, digoxin, glucocorticoids, benzodiazepines, cimetidine, ranitidine, cyclosporine, sulfonamides, metoclopramide. Choose medication on the basis of the symptom profile and anticipated side effect tolerability. Suicidality: One of the major comorbidities of untreated depression is suicidality. Age of onset is most commonly in the 20s and the 30s; the male-to-female ratio is 1:1.

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We should be recognized for our efforts that exceed our societal or organizational norms in a positive manner gastritis morning nausea purchase generic pariet canada. I submit that most of the time our intent in recognition is to gastritis symptoms bloating purchase pariet 20mg online generate a personal positive emotion in the target gastritis cats purchase pariet paypal. When the object is for society to diet when having gastritis buy pariet 20mg fast delivery gain appreciation for a particular person, then other additional forms of recognition are appropriate. I suspect that, in 2006, few Los Angeles drivers know that Rosecrans Boulevard, a major thoroughfare, is named after a Civil War General. They could look it up, however, and that may achieve the original goal of recognition. The few lines of meaningful words written and spoken by a sincere friend achieved a target goal for me. I think many others would appreciate and profit by a recognition form specifically appropriate to them. It is with regret that I relate that there is no intent to market these in the United States. In a conversation with the malaria officer on duty, my suggestion that they were of use was disparaged. Kain et al1 described an average delay of three days between the time of ordering a malaria smear and confirmation of the diagnosis in nonspecialist Canadian medical centers. In view of the rarity of malaria in this country, our best laboratory technicians are inexperienced in making this diagnosis and even experienced parasitologists can make errors in their reading of blood smears. One published small series2 from Bethesda Naval Hospital reviewed the diagnostic accuracy of these two modalities among Marines with febrile illness evacuated from Liberia. This would be even more significant for smaller hospitals in areas with less foreign travel among their patients. The accuracy of various tests does vary, but later generation tests for P falciparum routinely demonstrate sensitivities greater than 90% (88-99%) and specificities that are 95100%. The conclusion of the meta-analysis by Marx and colleagues4 is that "rapid testing will lead to the detection of most clinically relevant P falciparum cases, with considerably better accuracy than that expected from routine microscopy in nonspecialist settings. The monitoring progress, while vital, can be arranged once a diagnosis has been confirmed. The argument of heat sensitivity seems disingenuous in North America where laboratory reagents are controlled for quality and stored in nontropical conditions. Rapid diagnostic test for Plasmodium falciparum in 32 Marines medically evacuated from Liberia with a febrile illness. Meta-analysis: accuracy of rapid tests for malaria in travelers returning from endemic areas. In 1935, forced to choose between his highest domestic policy priorities-a minimum guaranteed income for the elderly and a national health insurance program- he picked the former (ie, Social Security) putting medical coverage on temporary hold. The resultant inflation spawned wage controls and, to remain competitive, employers offered health insurance as a substitute for salary increases. That precedent and a post-war economic boom contributed to enormous growth in employerbased health insurance. Note: Data on premium increases reflect the cost of health insurance premiums for a family of four. And now, with the relentless growth of health care expenditures, many American companies, faced with increasing competition due to globalization, have had to restrict or even jettison medical insurance coverage for their employees and retirees. Every fall, in an unwelcome annual rite, corporate benefit managers nervously await the survey of premium increases. Overwhelmed by these costs, for the first time the percentage of employees receiving insurance coverage dropped below 60% to 59% (Figure 2). One mechanism employers, particularly large companies, have used to rein in costs is the self-funding of health insurance coverage. In this strategy, the employer accepts the financial risk (and reward) and pays insurance companies a straightforward, fixed management fee. In California, Kaiser Permanente has an overhead of 7% (93% of premiums go directly to patient care) compared to 21. Though not well known to the public, self-funded plans have become a substantial book of business. With just about every employer large enough to participate in such plans already doing so, most of the costs have already been rung out of the system and, at this point, there is only room for marginal benefit. If self-funded insurance was to be the salvation of large companies, small employers put their hopes into the notion of consortia. A consortium is a mechanism through which companies could band together to purchase health care insurance, thereby gaining economies of scale and negotiating clout in the marketplace. Some underwriters predicted that, with only voluntary rather than firm contractual ties, such alliances would founder over time as individual businesses understandably placed their own interests ahead of the group. But the anticipated purchasing clout and administrative savings proved more imagined than real. Parenthetically, despite this history, another state has its eye on the consortium concept, albeit with a different population. In April 2006, the commonwealth of Massachusetts passed legislation that assures health insurance coverage to all its citizens. For companies with fewer than 50 employees, one element of this plan is a new, private, state-chartered clearinghouse called the Commonwealth Care Health Insurance Connector, or simply the Connector. Time will tell whether this iteration of a purchasing cooperative will be successful. The third and newest mechanism employers have used to constrain costs is consumer-directed health care. Consumer-directed health care is somewhat of a catchall, a term that includes high-deductible and high copay policies as well as health savings accounts, a tax-free vehicle for accumulating funds for out-ofpocket medical expenses. The principle of such plans is that consumers, forced to spend their own money up to the deductible limit, will be prudent shoppers for discretionary health care thereby lowering overall societal costs. Because of the high deductible (as much as $5000 a year), the overall costs and employee share of premiums can be held very low. Though untested, the policies have gained great favor among conservative economists and the Bush administration. In the 2006 Kaiser Family Foundation survey, fewer than 7% offered highdeductible or health savings accounts or both in 2006 and only 6% planned such programs in 2007. The much more common strategy (21%) was to simply charge employees more for the traditional coverage. Some employers, including WalMart, Freddie Mac and Capital One, have taken things into their own hands and opened workplace medical clinics. At the current rate, about a 1% loss per year, by 2015 fewer than half of Americans younger than age 65 years will receive health insurance through their employer. On the flip side, employers like the competitive advantage and control that providing health care coverage allows, not to mention the $126 billion annual tax break. And in the absence of a proven alternative, the 160 million Americans with employer-based coverage are unlikely to have much taste for political experimentation. Executive Summary-Roadmap to Coverage: Synthesis of Findings [monograph on the Internet]. Boston: Blue Cross Blue Shield of Massachusetts Foundation; 2005 Oct [cited 2006 Oct 6]. His lashes were sticky with secretions, and he seemed to me to be an obvious case of conjunctivitis. I reached in the top drawer to pull out my prescription pad, and glanced briefly back at Mr Toland. His hair was gray but had some blonde streaks, indicating the color it had been in his youth. Mr Toland and I had unexpectedly become more fully human at a walk-in appointment. However, compared to Caucasians, African Americans reported significantly more barriers to glucose self-testing (p <. Although the study is limited by its cross-sectional design, future studies of its longitudinal extension will consider how depression and self-care behaviors interact over a six-month period to impact long-term outcomes. Beleaguered clinicians are unlikely to cultivate effective healing relationships with patients. In order to restore healing to health care, clinicians will need to reconnect with patients and their passion for the art of medicine. This study attempts to elucidate the barriers to more effective healing from the perspectives of both patients and providers.

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If oliguria or hypotension occurs in a neonate with in utero exposure to gastritis diet 8 plus 20 mg pariet with mastercard enalapril/enalaprilat gastritis reviews buy 20mg pariet visa, exchange transfusions or dialysis may be needed to gastritis diet journal template cheap pariet 20 mg with mastercard reverse hypotension and/or support renal function gastritis symptoms vomiting purchase 20mg pariet with mastercard. Accidental injection into the digits, hands, or feet may result in the loss of blood flow to the affected area. For adults, discontinue therapy if Hgb does not increase after 8 wk of the 300 U/kg/dose 3 times per wk dosage. Iron supplementation recommended during therapy unless iron stores are already in excess. Withholding therapy: when Hgb > 11 g/dL; restart therapy at a 25% lower dose after Hgb decreases to target levels or < 11 g/dL. Vitamin D2 is activated by 25-hydroxylation in liver and 1-hydroxylation in kidney. Suppository: 2 mg at first sign of attack; follow with second 2 mg dose after 1 hr if needed; max. May produce elevated digoxin, theophylline, carbamazepine, clozapine, cyclosporine, and methylprednisolone levels. Injection, premixed infusion in iso-osmotic sodium chloride: 2000 mg/100 mL (100 mL), 2500 mg/250 mL (250 mL). May cause bronchospasm, congestive heart failure, hypotension (at doses > 200 mcg/kg/ min), nausea, and vomiting. Patients must be properly instructed on preparing and administering the medication. Reconstituted solutions should be clear and colorless as unused portions must be stored in the refrigerator and used within 14 days. Drug is administered subcutaneously by rotating injection sites (thigh, abdomen, or upper arm) with a max. May cause lupus-like syndrome; may increase frequency of grand mal seizures in patients with mixed type seizures. Carbamazepine levels may be decreased; however, phenytoin and valproic acid levels may be increased. Phenytoin and carbamazepine may increase felbamate clearance; valproic acid may decrease its clearance. Pregnancy category changes to "D" if drug is used for prolonged periods or in high doses at term. Dosage may be increased by 5 mcg/kg/24 hr if desired effect is not achieved within 7 days. May cause nausea, headache, rash, vomiting, abdominal pain, hepatitis, cholestasis, and diarrhea. Pediatric to adult dose equivalency: every 3 mg/kg pediatric dosage is equal to 100 mg adult dosage. Bone marrow suppression in immunosuppressed patients can be irreversible and fatal. No No 2 B All doses/24 hr (see table below): Recommendations from American Academy of Pediatrics and American Dental Association. Delayed-release capsule is currently indicated for depression and is dosed at 90 mg Q7 days. Dose may be increased to 2 sprays (100 mcg) per nostril once daily if inadequate response or severe symptoms. Proper patient education, including dosage administration technique, is essential; see patient package insert for detailed instructions. May mask hematologic effects of vitamin B12 deficiency but will not prevent the progression of neurologic abnormalities. Only use formoterol as additional therapy for patients not adequately controlled on other asthma-controller medications. Should not be used in conjunction with an inhaled, long-acting 2-agonist and is not a substitute for inhaled or systemic corticosteroids. Hypocalcemia (increased risk if given with pentamidine), hypokalemia, and hypomagnesemia may also occur. May cause hypokalemia, alkalosis, dehydration, hyperuricemia, and increased calcium excretion. Severe hypokalemia has been reported with a tendency for diuresis persisting for up to 24 hr after discontinuing metolazone. Somnolence, dizziness, ataxia, fatigue, and nystagmus were common when used for seizures (12 yr). Common side effects include neutropenia, thrombocytopenia, retinal detachment, and confusion. Avoid touching the applicator tip to eyes, fingers, or other surfaces, and do not wear contact lenses during treatment of ocular infections. May reduce effectiveness or decrease level of oral contraceptives, warfarin, and cyclosporine. When converting from an immediate-release tab to the extended-release tab, do not covert on an mg-per-mg basis (due to differences in pharmacokinetic profiles) but discontinue the immediate release and titrate with the extended-release product using the recommended dosing schedules. Due to recent regulatory changes to the manufacturing process, heparin products may exhibit decreased potency. C Injection: Amphadase and Hydase: 150 U/mL (1 mL); bovine source; may contain edetate disodium and thimerosal Hylenex: 150 U/mL (1 mL); recombinant human source; contains 1 mg albumin per 150 U Vitrase: 200 U/mL (1. Contraindicated in dopamine and -agonist extravasation and hypersensitivity to the respective product sources (bovine or ovine). Contraindicated in psoriasis, porphyria, retinal or visual field changes, and 4-aminoquinoline hypersensitivity. May decrease the effects of antihypertensives, aspirin (antiplatelet effects), furosemide, and thiazide diuretics. Most common reported side effects in clinical trials include nausea, flatulence, vomiting, and headache. Neoprofen doses must be administered within 30 min of preparation and infused intravenously over 15 min. Doses may be administered into multiple sites (spaced 2 inches apart) simultaneously. Diluted concentrations of 1 U/mL or 10 U/mL may be necessary for smaller doses in neonates and infants. Use with caution in dehydration, previous allergic reaction to a contrast medium, iodine sensitivity, asthma, hay fever, food allergy, congestive heart failure, severe liver or renal impairment, diabetic nephropathy, multiple myeloma, pheochromocytoma, hyperthyroidism, and sickle cell disease. Iohexol is particularly useful when barium sulfate is contraindicated in patients with suspected bowel perforation or those where aspiration of contrast medium is of concern. Use with caution in narrow-angle glaucoma or bladder neck obstruction, although ipratropium has fewer anticholinergic systemic effects than atropine. Reversible anisocoria may occur with unintentional aerosolization of drug to the eyes, particularly with mask nebulizers. Combination ipratopium and albuterol products are currently approved for use only in adults and have not been officially studied in children.

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Syndromes

  • Drainage of CSF from the nose (rarely)
  • Friends may be more willing to be in your car or home
  • Surgery to place ear tubes
  • Open
  • Chest x-ray
  • Swelling of the brain
  • Swelling of the lips, tongue, or face
  • You should be at least 18 years old (21 in some cases, depending on the laser used), because vision may continue to change in people younger than 18. A rare exception is a child with one very nearsighted and one normal eye. Using LASIK to correct a very nearsighted eye may prevent amblyopia (lazy eye).

Moeschler Clarren syndrome

Aneurysms can cause various ill-effects such as thrombosis and thromboembolism gastritis peptic ulcers symptoms generic pariet 20 mg without prescription, alteration in the flow of blood gastritis diet en espanol purchase generic pariet canada, rupture of the vessel and compression of neighbouring structures gastritis and diet pills cheap pariet 20mg visa. Aneurysms can be classified on the basis of various features: Depending upon the composition of the wall 1 True aneurysm composed of all the layers of a normal vessel wall gastritis vomiting purchase pariet in india. They are seen more commonly in males and the frequency increases after the age of 50 years when the incidence of complicated lesions of advanced atherosclerosis is higher. G/A Atherosclerotic aneurysms of the abdominal aorta are most frequently infra-renal, above the bifurcation of the aorta. Atherosclerotic aneurysm is most frequently fusiform in shape and the lumen of aneurysm often contains mural thrombus. M/E There is predominance of fibrous tissue in the media and adventitia with mild chronic inflammatory reaction. The intima and inner part of the media show remnants of atheromatous plaques and mural thrombus. It causes arteritis-syphilitic aortitis and cerebral arteritis, both of which are already described in this chapter. One of the major complications of syphilitic aortitis is syphilitic or luetic aneurysm that develops in the tertiary stage of syphilis. The process begins from inflammatory infiltrate around the vasa vasorum of the adventitia, followed by endarteritis obliterans. G/A Syphilitic aneurysms occurring most often in the ascending part and the arch of aorta are saccular in shape and usually 3-5 cm in diameter. The adventitia shows fibrous thickening with endarteritis obliterans of vasa vasorum. Various conditions causing weakening in the aortic wall resulting in dissection are as under: i) Hypertensive state hypertension. In 95% of cases, there is a sharply-incised, transverse or oblique intimal tear, 3-4 cm long, most often located in the ascending part of the aorta. The dissection is seen most characteristically between the outer and middle third of the aortic media so that the column of blood in the dissection separates the intima and inner two-third of the media on one side from the outer one-third of the media and the adventitia on the other. M/E Salient features are: i) Focal separation of the fibromuscular and elastic tissue of the media. Though the process may involve intima, media or adventitia, medial fibroplasia is the most common. The main effects of renal fibromuscular dysplasia, depending upon the region of involvement, are renovascular hypertension and changes of renal atrophy. The veins of lower extremities are involved most frequently, called varicose veins. The veins of other parts of the body which are affected are the lower oesophagus (oeso- 242 phageal varices), the anal region (haemorrhoids) and the spermatic cord (varicocele). About 10-12% of the general population develops varicose veins of lower legs, with the peak incidence in 4th and 5th decades of life. Adult females are affected more commonly than the males, especially during pregnancy. This is attributed to venous stasis in the lower legs because of compression on the iliac veins by pregnant uterus. G/A the affected veins, especially of the lower extremities, are dilated, tortuous, elongated and nodular. M/E There is variable fibromuscular thickening of the wall of the veins due to alternate dilatation and hypertrophy. Degeneration of the medial elastic tissue may occur which may be followed by calcific foci. M/E the thrombus that is attached to the vein wall induces inflammatoryreparative response beginning from the intima and infiltrating into the thrombi. Local effects are oedema distal to occlusion, heat, swelling, tenderness, redness and pain. Systemic effects are more severe and occur due to embolic phenomena, pulmonary thromboembolism being the most common and most important. Superior vena caval syndrome Superior vena caval syndrome refers to obstruction of the superior vena cava. Inferior vena caval syndrome Inferior vena caval syndrome is the obstruction of the inferior vena cava. Chronic lymphangitis occurs due to persistent and recurrent acute lymphangitis or from chronic infections like tuberculosis, syphilis and actinomycosis. Lymphoedema praecox this is a rare form of lymphoedema affecting chiefly young females. Various causes of lymphatic obstruction causing lymphoedema are as under: i) Lymphatic invasion by malignant tumour. Rupture of dilated large lymphatics may result in escape of milky chyle into the peritoneum (chyloperitoneum), into the pleural cavity (chylothorax), into pericardial cavity (chylopericardium) and into the urinary tract (chyluria). On the other hand, there are true vascular tumours which are of intermediate grade and there are frank malignant tumours. Clinically, they appear as small or large, flat or slightly elevated, red to purple, soft and lobulated lesions, varying in size from a few millimeters to a few centimeters in diameter. The common sites are the skin, subcutaneous tissue and mucous membranes of oral cavity and lips. These vessels are lined by single layer of plump endothelial cells surrounded by a layer of pericytes. They are most common in the skin (especially of the face and neck); other sites are mucosa of the oral cavity, stomach and small intestine, and internal visceral organs like the liver and spleen. M/E Cavernous haemangiomas are composed of thin-walled cavernous vascular spaces, filled partly or completely with blood. True to its name, it appears as exophytic, red granulation tissue just like a nodule, commonly on the skin and mucosa of gingiva or oral cavity. Pregnancy tumour or granuloma gravidarum is a variant occurring on the gingiva during pregnancy and regresses after delivery. M/E It shows proliferating capillaries similar to capillary haemangioma but the capillaries are separated by abundant oedema and inflammatory infiltrate, thus resembling inflammatory granulation tissue. It is a small, circumscribed, slightly elevated lesion measuring 1 to 2 cm in diameter. M/E Capillary lymphangioma is composed of a network of endotheliumlined, capillary-sized spaces containing lymph and often separated by lymphoid aggregates. A large cystic variety called cystic hygroma occurs in the neck producing gross deformity in the neck. M/E Cavernous lymphangioma consists of large dilated lymphatic spaces lined by flattened endothelial cells and containing lymph. These tumours are found most often in the dermis of the fingers or toes under a nail. M/E the tumours are composed of small blood vessels lined by endothelium and surrounded by aggregates, nests and masses of glomus cells. In fact, it is an opportunistic infection with gram-negative bacilli of Bartonella genus. M/E Lobules of proliferating blood vessels are seen lined by epithelioid endothelial cells having mild atypia. Mixed inflammatory cell infiltrate with nuclear debris of neutrophils is present in these areas. It is found most often in the skin and subcutaneous tissue in relation to medium-sized and large veins. M/E There is an active proliferation of endothelial cells forming several layers around the blood vessels so that vascular lumina are difficult to identify. Reticulin stain delineates the pattern of cell proliferation inner to the basement membrane. Pericytes are cells present external to the endothelial cells of capillaries and venules. This is a rare tumour that can occur at any site but is more common in lower extremities and the retroperitoneum. M/E the tumour is composed of capillaries surrounded by spindle-shaped pericytes outside the vascular basement membrane forming whorled arrangement.

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