![]() ![]() 15 Granulocyte function in affected individuals appears to be normal. However, nuclei of neutrophils in patients with PHA are not segmented due to a complete or partial lack of functional LBR. 14 LBR is an inner nuclear membrane protein that anchors the lamina and the heterochromatin to the inner nuclear membrane and has been shown to be significant for the normal morphologic maturation of granulocytes. 13 The lamin B receptor is an evolutionary conserved, multifunctional protein. 3 It has been reported that the lamin B receptor (LBR) mutations are the cause of PHA in humans. The nucleus is bounded by a membrane system called the nuclear envelope (NE), which consists of outer nuclear membrane (ONM) and the inner nuclear membrane (INM). Its distinct nuclear shape facilitates rapid diapedesis through vessel walls and chemotaxis through interstitial spaces, respectively. The human neutrophil has a lobulated nucleus containing condensed chromatin. 11 Presumed homozygous individuals have ovoid neutrophil nuclei, as well as varying degrees of developmental delay, epilepsy and skeletal abnormalities. An incidence of one in 6000 is reported by Ayan et al. 9 In humans, it is found rather rarely in a heterozygous state, according to Shetty et al. The PHA is also present in other mammals such as mice, 5 dogs, 6 cats, 7 horses 8 and rabbits. 5 The distribution of the anomaly is worldwide. In humans the PHA prevalence is between 0.01% and 0.1%, the anomaly affects the white people, black and Asian in all ages and in equal ratio between males and females. The Pelger-Huët anomaly is considered to be a familial anomaly and it is not connected with any pathologic state. Huët realize that the aberrant neutrophil morphology was a benign autosomal dominant inherited and surely not acquired change associated with a poor prognosis for tuberculosis. 3 Moreover, while examining smears of peripheral blood showed the Pelger anomaly in several of the child’s relatives. 4 In fact, Huët was pediatrician and he recognized the “Pelger anomaly” in a 7-year-old girl with tuberculosis who recovered from her illness. 3 Only three years later, Huët, who was also a Dutch, pronounced it as an inherited disorder. Pelger believed that the anomaly was associated with a poor prognosis in patients with tuberculosis because both patients died. ![]() Observed neutrophils had bilobed nuclei, but also a coarse clumping of the nuclear chromatin. 2 The neutrophil with characteristic appearance was first reported in two patients diagnosed with disseminated tuberculosis in 1928 by a Dutch hematologist-Karl Pelger. The nuclear shape of affected granulocytes resembles bands, metamyelocytes or myelocytes however, the chromatin pattern appears aggregated and mature. 1 The PHA has distinctive nuclear hyposegmentation of not only neutrophils, but also other granulocytes and monocytes, as well. However, neutrophils hyposegmentation also occurs with Pelger-Huët anomaly (PHA). Nevertheless, finding a total leukocyte number within reference interval, presence of immature hyposegmented neutrophils in increased numbers (a left shift) suggests an inflammatory leukogram. Morphologic evaluation of leukocytes by microscopic examination of a blood film is an essential part of the complete blood count (CBC).
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Starfire was later tricked into continuing the holiday season by Beast Boy, Raven, and Cyborg yet the three of them were extremely guilty due to her childlike nature in wanting to experience the Second Christmas Miracle. When Beast Boy was looking for someone to prank, he immediately singled out Starfire for her gullibility and tricked her into serving his every whim after she believed that she had killed him. Īs a result of her naivety, Starfire is often at the receiving end of pranks from the Titans and this trait is occasionally exploited by her enemies. She has a high sense of responsibility and morality as seen when she confessed about her lying and volunteered to leave the Titans because of it (which also highlighted a high regard for herself). ![]() Due to the sharp contrast that lying has against her personality, Starfire finds it hard to tell a simple lie, but became fluent which resulted in fights between by her friends. Starfire's innocence is shown to have a powerful affect on the Titans, and her puppy dog eyes often succeed in winning them over without a fight. Her kindness and overall good nature has earned her a reputation which includes always telling the truth and unable to fill the the merciless actions that are required of a supervillain. Her sunny personality, politeness, and kindness is shared among both friends and even her enemies such as Jinx, Doctor Light, and the H.I.V.E. Starfire is kind hearted, joyous, and optimistic, preferring to see the good in every situation to the opposite of apathetic Raven. ![]() Starfire usually displays an aura of kindness and innocence. History Main article: History of Starfire Personality ![]()
![]() So read his book Mastery (Amazon) so that you can figure your life’s task and how to dedicate yourself to it. It must be joined to mastery and purpose. People have power over us, we seek power ourselves that we might be free enough and influential enough to accomplish our goals-so we must understand where power comes from, how it works and how to get it. In life, power is force we are constantly bumping up against. His work on power and strategy are critical for anyone trying to accomplish anything. I met him when I was 19 years old and he’s shaped me as a person, as a writer, as a thinker. His other two books on the topic, Will To Meaning (Amazon) and Man’s Search for Ultimate Meaning (Amazon) have gems in them as well.Ĥ8 Laws of Power and Mastery by Robert Greene (Amazon) There is no living writer (or person) who has been more influential to me than Robert Greene. He looks at how we find purpose by dedicating ourselves to a cause, learning to love and finding a meaning to our suffering. His contribution was to change the question from the vague philosophy of “What is the meaning of life?” to man being asked and forced to answer with his actions. Man’s Search for Meaning by Viktor Frankl (Amazon) Frankl is one of the most profound modern thinkers on meaning and purpose. You can draw a pretty straight line from Seneca to the essays of Montaigne (also read: How To Live (Amazon), a biography of Montaigne) to the modern day writings of Nassim Nicholas Taleb (read: The Black Swan (Amazon), Fooled By Randomness (Amazon) and The Bed of Procrustes (Amazon) ). Seneca’s letters are the best place to start, but the essays in On the Shortness of Life (Amazon) are excellent as well. His advice on grief, on wealth, on power, on religion, and on life are always there when you need them. In fact, that was his job-he was Nero’s tutor, tasked with reducing the terrible impulses of a terrible man. While Marcus wrote mainly for himself, Seneca had no trouble advising and aiding others. Letters from a Stoic by Seneca (Amazon) After Marcus Aurelius, this is one of my favorite books. And if you want more on the topic, Marcus inspired my book The Obstacle is the Way (Amazon). If you end up loving Marcus, go get The Inner Citadel (Amazon) and Philosophy as a Way of Life (Amazon) by Pierre Hadot that studies the man (and men) behind the work. If you read it and aren’t profoundly changed by it, it’s probably because as Aurelius says “what doesn’t transmit light creates its own darkness.” You HAVE to read the Hays’s translation. It is the definitive text on self-discipline, personal ethics, humility, self-actualization and strength. Just imagine: the private thoughts of the most powerful man in the world, admonishing himself on how to be better, more just, more immune to temptation, wiser. The Meditations by Marcus Aurelius (Amazon) To me, this is not only one of greatest books ever written but perhaps the only book of its kind. And don’t forget to sign up for my Reading List Email which recommends a new set of life changing books each month. And then when you come to a dead end, come back to the list. Pick one of them up and let it lead you to another. It’s a list that has changed over time-and will continue to change-but it’s a good enough place to start. Having been introduced to them by those kind, patient individuals, I thought I would pay it forward by putting together a list of the books that have shaken up my life and that have helped make me the person that I am. The quake books- as Tyler Cowen put it -that shake you to your core. That’s how I found many of the books on the list below. I used to go around and ask every smart person I met-even emailing important people I didn’t know- “What books do you recommend to a kid like me?” That’s how I was introduced to the Stoics. My whole life and career, I’ve been seeking out, reading, and taking notes on books that can teach me things. ![]() There is a Latin expression: liber medicina animi (a book is the soul’s medicine). As Petrarch, a famous book lover observed some 700 years ago, “books give delight to the very marrow of one’s bones.” But if I was honest, I would say the real reason that I’ve spent so much time with my nose inside this book or that book is because I have been searching for something: a way to life. Obviously a big reason to read is because it’s fun. “I’m not saying that you have to be a reader to save your soul in the modern world. ![]() Roots are shallow at this stage, so be careful when thinning. Better spacing also decreases the plant's susceptibility to disease and pests. Failure to thin out seedlings can result in stunted growth and premature bolting. Again, check the seed packet for specific varietal recommendations. Spinach plants need four to six inches of space to develop properly. Thin out the plants as they reach two inches in height. Moisture on the leaves can encourage fungal diseases. When you must supplement with irrigation, water the soil, not the plant leaves. When spinach bolts, it sends up a strong central stem to produce seed, and it becomes bitter and inedible. Try to keep the soil consistently moist because spinach will bolt if the soil dries out. ![]() ![]() Optimum growing temperature is 50⁰ F to 60⁰ F, but young seedlings can tolerate temperatures as low as 15⁰ F to 20⁰ F. Keep the cover on until the weather warms. During light rainy days, remove the plastic cover for a good soaking. Within 7 to 10 days, the first signs of sprouting usually appear as the cotyledon (seed leaves) emerge. The plastic cover serves as a greenhouse, encouraging leaf growth on those early spring days. A framework over the bed keeps the plastic from direct contact with the spinach and prevents stem damage if snow, rain or ice builds up on the plastic cover. When planting in early spring, shelter the seeds with a clear polypropylene cover over the raised bed for the first few weeks. Understanding the relationship of spinach to temperature is critical to achieving success. Two crops per year can be achieved! Many home gardeners have become discouraged growing spinach because they start too late in the spring. Recommendations are to plant spinach about four to eight weeks before your average last frost date in the spring and six to eight weeks before the average first frost date in the fall. Spinach seeds germinate best in a soil temperature of 45⁰ F to 68⁰F. One key to successfully growing spinach is to plant the seeds when soil temperatures are cool. You can grow spinach in a container, but choose varieties specifically suited to it, a container large enough for it, and a nutrient-rich soilless potting mix. If you are following intensive gardening plans, such as Mel Bartholomew's square foot gardening, plant 9 seeds per square foot. Sow the seeds ½ inch deep two inches apart, in rows 12 to 18 inches apart. Mature spinach has a long taproot, so loosen the soil to between 12 and 18 inches. Mini-till or spade the ground and level it off with a rake. Prepare the planting bed by amending the soil with rich compost or aged manure. Spinach likes full sun but will tolerate partial shade. A raised bed with good drainage is perfect for growing an early spring crop since the soil warms quickly and can be worked following just a few warm days. Always check the seed packet for specific varietal recommendations. For best results, use fresh seeds as the germination rate for this crop deteriorates quickly. Select a variety of spinach for growing and a garden area for planting. Spinach is versatile in the kitchen and packs a powerhouse of nutrients: iron potassium magnesium vitamins A, B6, B9, C and E and lutein. ![]() Spinach stores well in the refrigerator or can be blanched and frozen for later use. The many varieties of spinach include smooth-leaf, savoy or curly leaf, arrowhead, and savory. Spinach ( Spinacia oleracea) is a vitamin-rich, delicious, leafy green that is best grown in the cool weather of either spring or fall. About 6 to 10 aortic nodes are located to the left, anterior and posterior to the aorta. As noted in Figure 1, three para-aortic node chains exist. However, cervical cancer can occasionally metastasize directly to the para-aortic nodes by embolization through the posterior trunks. Para-aortic nodal spread is usually by an orderly, progressive involvement of the pelvic and common iliac nodes. The three para-aortic lymph node chains are illustrated: the left aortic chain (I) lies to the left of the aorta, the aortocaval nodes (II) lie between the aorta and vena cava, and the caval chain (III) lies to the right of the vena cava. The anterior channels (C) pass behind the bladder and terminate predominantly in the external iliac lymph nodes the posterior lymphatic channels (A) course posteriorly and caudad in the uterosacral ligaments before turning cephalad and terminating in the common iliac, subaortic, para-aortic, and superior rectal lymph nodes. In addition to the lateral lymphatic trunks, smaller but consistent anterior and posterior lymphatic trunks are present. The major lymphatic drainage of the cervix is through the lateral channels (B) to the external iliac, hypogastric, obturator, and common iliac lymph nodes. Posterior channels drain directly into the common iliac and para-aortic nodes and superior rectal nodes.įig. 3 Also, small anterior channels pass behind the bladder and terminate in the external iliac nodes. These course through the parametria and drain to the external iliac, hypogastric, obturator, and common iliac nodes (Fig. The lymphatic channels draining the cervix converge to form lateral trunks. It is more likely to occur with large-volume tumors and if several lymphatic spaces are involved. If these spaces are involved, lymphatic embolization to regional lymph nodes can occur. Lymphatic spaces are present within 1 to 2 mm of the basement membrane. 2 The obstruction usually occurs in the distal third of the ureter. About one third of patients with stage IIIB cancers have ureteral obstruction, and about 5% have bilateral obstruction. The anatomic position of the ureter (within 2 cm of the uterine cervix) makes the ureter vulnerable to involvement. Lateral spread to the parametria mandates some type of radiologic evaluation of the ureters. As will later be enumerated, most traditional testing can be avoided in early-stage diseases, particularly when operative intervention is planned. These observations are important in the decision to order expensive tests in this era of cost containment. Anterior spread to the bladder is unusual in the absence of large-volume tumors with parametrial extension. Rectal spread is usually associated with posterior vaginal involvement. It may spread posteriorly to involve the rectum or the uterosacral ligaments. Another common pattern of spread is distal, to involve the vaginal fornices and later (and with larger-volume tumors) the midportion and distal third of the vagina. In this scenario, the cardinal ligaments eventually are involved. If the basement membrane is intact and stromal invasion is absent, dissemination and metastases do not occur.Ĭervical cancer usually extends by lateral spread to involve the parametria, following a path of least resistance. The progression of squamous cell neoplasias to invasive carcinomas was addressed in earlier chapters. Hematogenous dissemination usually occurs with more advanced disease or unusual cell types, such as adenosquamous or neuroendocrine tumors. Traditional and more modern pretreatment diagnostic modalities will be explored.ĭirect local extension and lymphatic embolization are the primary routes of spread of cervical carcinoma. ![]() The purpose of this chapter is to review the usual patterns of spread of cervical cancer. Although workup and studies are indicated for all patients with clinically advanced disease, immunocompromised patients should have extensive workups before treatment modalities are chosen. ![]() These patients include those with immunocompromised states, such as renal transplant patients or those who test positive for HIV on serum testing. However, at the outset, it should be emphasized that a subgroup of patients with invasive cervical cancer are at greater risk for a more aggressive cervical cancer and for more advanced stage. 1 The epidemiology of this disease was reviewed in an earlier chapter. In 2001, an estimated 12,900 cases of invasive cervical cancer will have occurred in the country, and more than 4,400 women will have died from cervical cancer. 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