WEBVTT 1 00:00:08.541 --> 00:00:08.942 Hello. 2 00:00:08.942 --> 00:00:11.811 Welcome to our red blood cell seminar. 3 00:00:11.811 --> 00:00:15.315 Today we'll talk about, the shape of red blood cells. 4 00:00:15.515 --> 00:00:17.517 So I named it all about the looks. 5 00:00:17.517 --> 00:00:19.652 My name is Doctor Anton Rats. 6 00:00:19.652 --> 00:00:23.123 And I am an associate professor of pathology and medical director of human 7 00:00:23.123 --> 00:00:26.126 to pathology at RPA laboratories. 8 00:00:26.192 --> 00:00:29.496 So today we will go over four main points. 9 00:00:30.030 --> 00:00:33.233 We will learn even more about routine morphologic 10 00:00:33.233 --> 00:00:35.135 assessment of peripheral blood. 11 00:00:35.135 --> 00:00:38.238 We will be able to correlate certain things 12 00:00:38.238 --> 00:00:41.241 we see on the sphere with the CPK parameters. 13 00:00:41.374 --> 00:00:46.346 We will talk about pathogenesis of some changes in the peripheral blood smear. 14 00:00:46.679 --> 00:00:50.283 And we also will be able to connect the morphology on the smear 15 00:00:50.517 --> 00:00:53.520 to a potential diagnosis. 16 00:00:54.054 --> 00:00:56.990 So today we'll talk about common particular sites. 17 00:00:56.990 --> 00:00:59.225 We'll start with Spiro sites and sites. 18 00:00:59.225 --> 00:01:01.194 Then we'll talk about stomata sites. 19 00:01:01.194 --> 00:01:04.030 Acanthus sites kind of sites. 20 00:01:04.030 --> 00:01:07.300 Bait cells target cells and sickle cells. 21 00:01:10.136 --> 00:01:12.605 As we know red blood cell in the normal smear 22 00:01:12.605 --> 00:01:18.745 looks like bi concave disk, usually seven microns in diameter, 23 00:01:18.978 --> 00:01:22.048 with a central pallor that takes about one third of the cell 24 00:01:22.916 --> 00:01:26.653 sphere sites, or abnormal shape of the red blood cells. 25 00:01:27.120 --> 00:01:28.822 That looks like a sphere. 26 00:01:28.822 --> 00:01:33.126 So by definition, sphere cells will not have any central pallor. 27 00:01:34.160 --> 00:01:37.630 Here I, highlighted a couple of sphere sites 28 00:01:37.831 --> 00:01:41.534 like this one, this one, and a couple here. 29 00:01:42.302 --> 00:01:47.040 Sphere sites usually have a smaller size compared to normal red blood cells, 30 00:01:47.340 --> 00:01:51.277 and sometimes they can be referred to as micro sphere sites. 31 00:01:51.945 --> 00:01:55.148 As we said, they maintain their round shape 32 00:01:55.548 --> 00:01:58.551 and they lose their central pallor. 33 00:01:58.885 --> 00:02:02.021 Sphere sites form because there is imbalance 34 00:02:02.021 --> 00:02:05.992 between the content of red blood cell and the amount of surface 35 00:02:05.992 --> 00:02:10.230 of red blood cells, and in the way they represent an overfilled wallet. 36 00:02:10.263 --> 00:02:13.233 So this is what happens right after you get paid. 37 00:02:13.433 --> 00:02:14.534 You have a small wallet. 38 00:02:14.534 --> 00:02:18.338 You stuff it up with with the money or the driver license, other things. 39 00:02:18.571 --> 00:02:21.174 So it becomes a big puffy thing. 40 00:02:21.174 --> 00:02:23.143 So this is exactly what Sphere site is. 41 00:02:24.144 --> 00:02:25.612 One caveat when we look for 42 00:02:25.612 --> 00:02:29.616 sphere of size is to always stay away from the feathered edge. 43 00:02:29.616 --> 00:02:34.254 As we remember, feather edge has artificial increase in sphere of size. 44 00:02:34.287 --> 00:02:38.391 So if you're not careful, you definitely can and can overestimate, 45 00:02:38.791 --> 00:02:41.728 micro sphere sites. 46 00:02:41.728 --> 00:02:43.062 Here is also a great time 47 00:02:43.062 --> 00:02:46.065 to talk about, the red blood cell membrane. 48 00:02:46.499 --> 00:02:49.502 And a great analogy that I can think of is, 49 00:02:49.736 --> 00:02:52.739 people in Mongolia building a yogurt. 50 00:02:52.906 --> 00:02:56.876 So in order for your to be a sturdy, they actually start with, 51 00:02:57.377 --> 00:03:01.447 very stiff skeleton that is composed of sticks. 52 00:03:02.282 --> 00:03:05.285 Those sticks are tightly tied together. 53 00:03:05.285 --> 00:03:10.056 And then on top of those sticks, the people place kind of more fluid. 54 00:03:11.024 --> 00:03:13.293 Canvas, in many ways, 55 00:03:13.293 --> 00:03:16.262 red blood cell membrane looks very similar. 56 00:03:16.696 --> 00:03:18.498 The skeleton that is very stiff 57 00:03:18.498 --> 00:03:21.601 and rigid is actually formed by molecules of spectrum. 58 00:03:21.601 --> 00:03:23.903 There's alpha spectrum. There is beta spectrum. 59 00:03:25.471 --> 00:03:26.372 The canvas 60 00:03:26.372 --> 00:03:30.376 is represented by the, membrane of the red blood cell. 61 00:03:30.910 --> 00:03:33.479 And what's important is that this membrane membrane 62 00:03:33.479 --> 00:03:36.883 is attached to the cytoskeleton in a very efficient manner. 63 00:03:38.384 --> 00:03:41.821 So, what happens in sphere, say, ptosis, 64 00:03:42.121 --> 00:03:45.592 is that there are two different ways, for a sphere of size to form. 65 00:03:46.226 --> 00:03:49.796 One of them is represented by hereditary sphere statuses. 66 00:03:50.230 --> 00:03:53.166 So hereditary status is a genetic defect 67 00:03:53.166 --> 00:03:56.469 that affects vertical cytoskeletal membrane interaction. 68 00:03:57.003 --> 00:04:00.340 So when the red blood cell has very, flaccid 69 00:04:00.840 --> 00:04:03.843 membrane that is not well attached to the cytoskeleton, 70 00:04:04.544 --> 00:04:07.113 it forms little vesicles on its surface. 71 00:04:07.113 --> 00:04:10.183 And as the red blood cell circulates, especially through the spleen, 72 00:04:10.450 --> 00:04:13.753 those vesicle bicycles will, eventually detach. 73 00:04:14.520 --> 00:04:17.557 Decreasing the surface area of the red blood cell, 74 00:04:18.057 --> 00:04:21.227 because there's no, content of the red blood cell that's lost. 75 00:04:21.661 --> 00:04:26.633 The red blood cell will change its shape from being a disc to a sphere of site. 76 00:04:27.900 --> 00:04:29.168 Alternatively, sphere 77 00:04:29.168 --> 00:04:32.205 cells can form when there is antibody 78 00:04:32.372 --> 00:04:35.375 that is produced to this red blood cell. 79 00:04:35.942 --> 00:04:38.911 The antibodies are attached to the red blood cell membrane. 80 00:04:39.178 --> 00:04:40.046 And as a red blood 81 00:04:40.046 --> 00:04:44.517 cell goes through the spleen, the macrophages recognize the antibody. 82 00:04:44.517 --> 00:04:46.386 And they will pinch out that antibody. 83 00:04:46.386 --> 00:04:49.122 And a tiny bit of the red blood cell membrane. 84 00:04:49.122 --> 00:04:51.591 And as the cell goes 85 00:04:51.591 --> 00:04:55.461 in circles, you know, back to the spleen and back to the spleen. 86 00:04:55.461 --> 00:04:58.564 Over time, it will also lose its surface, 87 00:04:59.332 --> 00:05:02.335 creating sphere sites. 88 00:05:02.702 --> 00:05:04.871 The next important, 89 00:05:04.871 --> 00:05:07.707 particular site in this category would be ovals site. 90 00:05:07.707 --> 00:05:10.410 And sometimes they also referred as slip to sites. 91 00:05:10.410 --> 00:05:14.814 So those are elongated red blood cell like highlighted with this arrows. 92 00:05:16.683 --> 00:05:19.319 The central pallor for the most part is preserved. 93 00:05:20.420 --> 00:05:22.021 And the ends 94 00:05:22.021 --> 00:05:25.024 usually stain a little bit darker. 95 00:05:26.359 --> 00:05:30.330 So a valid site or a slip to site is another form of red blood cell 96 00:05:30.330 --> 00:05:35.201 that is due to, abnormal interaction between the cytoskeleton and the membrane. 97 00:05:35.668 --> 00:05:41.341 In this case, there is a problem with what we call horizontal interactions. 98 00:05:41.341 --> 00:05:44.344 So where our spectrums are met together 99 00:05:44.610 --> 00:05:49.515 because the spectrum, skeleton is not as rigid and stiff anymore 100 00:05:49.515 --> 00:05:53.186 as the red blood cell goes through narrow spaces, for example, small capillaries 101 00:05:53.186 --> 00:05:58.891 or in the spleen, it will, over time, change its shape and become elongated. 102 00:05:59.425 --> 00:06:02.662 So one of the, diseases that is characterized 103 00:06:02.662 --> 00:06:06.032 by increasingly decides is called hereditary ellipticity, ptosis. 104 00:06:06.599 --> 00:06:09.235 There are, however, some other causes of those sites. 105 00:06:09.235 --> 00:06:11.671 For example, iron deficiency anemia. 106 00:06:11.671 --> 00:06:14.907 My oldest classic syndromes and other hereditary anemia is, 107 00:06:17.176 --> 00:06:19.812 in the micro photographs, presented here, 108 00:06:19.812 --> 00:06:22.849 I wanted to show that the elliptic sides and novelists 109 00:06:22.849 --> 00:06:28.321 can, have quite, different, look to them, for example, in the case 110 00:06:28.321 --> 00:06:34.127 in case right here, we have kind of, shorter and fatter, elliptic sites. 111 00:06:34.360 --> 00:06:38.731 Whereas in this case of iron deficiency anemia, the elliptic sides 112 00:06:38.731 --> 00:06:41.701 become really skinny and very long. 113 00:06:43.836 --> 00:06:46.839 The next form to talk about is stomata sites. 114 00:06:46.939 --> 00:06:50.777 So the term stomata site, arose from the Greek word 115 00:06:52.211 --> 00:06:55.214 that means mouth or stomatitis. 116 00:06:55.715 --> 00:06:59.185 And as you see in the peripheral blood smears, those red blood cells, 117 00:06:59.185 --> 00:07:03.623 instead of having, round central pallor, they have this elongated 118 00:07:03.623 --> 00:07:06.793 pallor that reminds, some of us, 119 00:07:07.260 --> 00:07:10.263 of, fish mouth. 120 00:07:10.430 --> 00:07:12.298 So, this form 121 00:07:12.298 --> 00:07:15.301 of, abnormal red blood cells forms, 122 00:07:15.735 --> 00:07:19.605 because of either dehydration or over hydration of red blood cells. 123 00:07:20.339 --> 00:07:25.178 It can be commonly seen in a smears that is not properly, dried. 124 00:07:25.178 --> 00:07:29.348 So, it represents artifact, but if you see a lot of stomata cells, 125 00:07:29.348 --> 00:07:32.351 especially those that are oriented in different directions, 126 00:07:33.052 --> 00:07:37.223 sometimes it can manifest, hereditary estimators, say ptosis 127 00:07:37.223 --> 00:07:39.192 or genetic disorder, 128 00:07:39.192 --> 00:07:43.563 that is caused by mutations in the genes that encode for the membrane channels, 129 00:07:43.863 --> 00:07:47.467 either causing over hydration or dehydration of red blood cells. 130 00:07:50.203 --> 00:07:51.871 Let's move on to, 131 00:07:51.871 --> 00:07:55.575 red blood cells with spicules or with little pockets on their surface. 132 00:07:55.908 --> 00:07:58.911 There are two different types of, 133 00:07:59.645 --> 00:08:01.380 speculated red blood cells. 134 00:08:01.380 --> 00:08:04.617 The first type presented here are called a counter sites. 135 00:08:04.884 --> 00:08:07.887 Sometimes there are known as spur cells. 136 00:08:08.287 --> 00:08:10.890 So those are spheroid cells. 137 00:08:10.890 --> 00:08:14.126 Sometimes they can be not as spheroid as other times 138 00:08:15.328 --> 00:08:19.732 they can be of various a size, usually slightly smaller than your background. 139 00:08:19.732 --> 00:08:21.767 Red blood cells. 140 00:08:21.767 --> 00:08:24.770 Again, the sites tend to lose their central pallor. 141 00:08:25.238 --> 00:08:29.542 And the important feature of acanthus sites is the spicules on this surface. 142 00:08:30.443 --> 00:08:33.813 The speakers of acanthus sites usually have varying length. 143 00:08:33.813 --> 00:08:38.117 They're irregularly distributed, and they're usually not very numerous. 144 00:08:38.117 --> 00:08:41.854 For example, in the cell that is, highlighted by this arrow, 145 00:08:41.854 --> 00:08:45.791 we have one, two, three, four, five, six, seven, about seven spicules. 146 00:08:45.791 --> 00:08:49.262 And as you see once again they can be quite irregular in their shape 147 00:08:49.395 --> 00:08:50.963 in their distribution. 148 00:08:50.963 --> 00:08:54.500 This red blood cell will lose the central pallor and become slightly smaller. 149 00:08:55.401 --> 00:08:57.537 So the acanthus sites form because there's 150 00:08:57.537 --> 00:09:00.573 excess of lipids in the circulation. 151 00:09:00.573 --> 00:09:04.677 And so those lipids will accumulate in the outer, membrane 152 00:09:04.677 --> 00:09:08.247 of the red blood cell, changing the shape of this red blood cell. 153 00:09:08.748 --> 00:09:11.450 As such, acanthus sites, can be associated 154 00:09:11.450 --> 00:09:14.520 with, a very a broad spectrum of different diseases, 155 00:09:14.887 --> 00:09:19.292 including severe liver disease, beta lipoprotein anemia and splenectomy. 156 00:09:21.494 --> 00:09:22.428 It kind of site 157 00:09:22.428 --> 00:09:25.531 is a different type of speculated red blood cell. 158 00:09:26.265 --> 00:09:28.834 As you see in this image, there are quite 159 00:09:28.834 --> 00:09:31.837 a few red blood cells that are 160 00:09:32.371 --> 00:09:35.341 overall of normal size, 161 00:09:36.309 --> 00:09:37.977 rounder shape. 162 00:09:37.977 --> 00:09:40.980 They have retained central pallor, 163 00:09:41.213 --> 00:09:44.083 and they have quite numerous number of spicules 164 00:09:44.083 --> 00:09:47.753 that are uniform in their size, uniform in their shape, 165 00:09:47.987 --> 00:09:51.891 and uniform in their distribution, it kind of size. 166 00:09:51.891 --> 00:09:54.360 And the fact is a pretty common observation. 167 00:09:54.360 --> 00:09:58.764 And very often, it represents an artifact of drying 168 00:09:59.565 --> 00:10:02.535 and that the reason for it kind of sites to occur 169 00:10:02.535 --> 00:10:05.972 is when you have older specimen, when you have kidney disease. 170 00:10:05.972 --> 00:10:09.275 So there's a change, in the age of, 171 00:10:09.542 --> 00:10:12.612 the red blood cell and also pyruvate kinase deficiency. 172 00:10:14.113 --> 00:10:16.949 So let's summarize what we just learned about I can't 173 00:10:16.949 --> 00:10:21.454 I can't two sites and the kind of sites and compare and contrast them. 174 00:10:21.454 --> 00:10:24.457 So once again I can't the sites are smaller. 175 00:10:25.191 --> 00:10:28.628 They have fewer irregularly distributed spicules 176 00:10:29.462 --> 00:10:32.431 and they have a loss of central pallor. 177 00:10:33.065 --> 00:10:35.501 In contrast, it kind of sites, usually 178 00:10:35.501 --> 00:10:38.504 a larger size comparable to normal red blood cell. 179 00:10:38.604 --> 00:10:40.573 They retain their central pallor. 180 00:10:40.573 --> 00:10:45.077 They have more numerous spicules that are evenly distributed and evenly shaped. 181 00:10:45.711 --> 00:10:48.714 It kind of sites, as was said, is a common artifact. 182 00:10:49.115 --> 00:10:53.152 Whereas when you see in an encounter site, it usually is associated 183 00:10:53.152 --> 00:10:54.153 with a real disease. 184 00:10:56.656 --> 00:10:59.358 The next form, which is very important 185 00:10:59.358 --> 00:11:02.361 to be recognized in the peripheral blood smears, it's basal, 186 00:11:03.062 --> 00:11:04.897 as shown on this bit. 187 00:11:04.897 --> 00:11:08.334 An apple by cells, look like red blood cells 188 00:11:08.334 --> 00:11:11.337 that got bitten off. 189 00:11:11.437 --> 00:11:13.105 How do they form? 190 00:11:13.105 --> 00:11:15.207 So the bite cells form 191 00:11:15.207 --> 00:11:18.978 because there is a denatured hemoglobin in the red blood cell. 192 00:11:19.879 --> 00:11:22.381 Denatured hemoglobin has also red color. 193 00:11:22.381 --> 00:11:25.951 That's why it's very difficult sometimes to see it in right. 194 00:11:25.951 --> 00:11:28.020 Gives a stain, smears. 195 00:11:28.020 --> 00:11:30.189 Why does hemoglobin denature? 196 00:11:30.189 --> 00:11:33.025 There are different causes of this phenomenon. 197 00:11:33.025 --> 00:11:34.860 It can be an abnormal hemoglobin. 198 00:11:34.860 --> 00:11:38.330 For example there is a mutation in the hemoglobin gene 199 00:11:38.597 --> 00:11:41.333 that creates what we call unstable hemoglobin. 200 00:11:41.333 --> 00:11:44.503 Or it can be increased oxidation of normal hemoglobin 201 00:11:45.237 --> 00:11:48.374 that increase oxidation can be either to, 202 00:11:48.641 --> 00:11:54.346 decrease the activity of a glucose six phosphate dehydrogenase or administration 203 00:11:54.346 --> 00:11:58.818 of oxidative drugs, or alternatively, ingestion of oxidative toxins. 204 00:12:00.453 --> 00:12:03.823 So if there is a precipitation of unstable hemoglobin 205 00:12:03.823 --> 00:12:06.826 in the red blood cell, it actually damages the red blood cell. 206 00:12:06.859 --> 00:12:08.761 Very often this, 207 00:12:08.761 --> 00:12:12.765 hemoglobin will precipitate on the red blood cell membrane. 208 00:12:13.299 --> 00:12:16.135 And as the red cell circulates through the spleen, 209 00:12:16.135 --> 00:12:21.340 and it has to go through a very narrow window in that splenic sinusoid, 210 00:12:21.707 --> 00:12:24.510 the portion of the red blood cell with unstable hemoglobin 211 00:12:24.510 --> 00:12:27.613 can be pinched off, alternatively creating this, 212 00:12:28.881 --> 00:12:31.884 by cell morphology. 213 00:12:34.153 --> 00:12:35.788 As seen from the 214 00:12:35.788 --> 00:12:39.959 a name of the target cell, does actually look like a target. 215 00:12:40.059 --> 00:12:44.330 So target cells are defined as red blood cells usually round. 216 00:12:44.330 --> 00:12:47.867 And they have a darker peripheral area 217 00:12:47.867 --> 00:12:50.870 as well as darker central area. 218 00:12:51.203 --> 00:12:54.273 Target cells form when there is imbalance 219 00:12:54.273 --> 00:12:57.376 in the content to membrane ratio. 220 00:12:58.043 --> 00:13:01.046 In a situation where we have either too little content 221 00:13:01.280 --> 00:13:04.283 or too much of the membrane, 222 00:13:04.283 --> 00:13:07.887 it can be, The decreased content is usually seen in iron deficiency 223 00:13:08.154 --> 00:13:13.325 or in thalassemia, whereas increased membrane surface would be seen 224 00:13:13.325 --> 00:13:18.063 in, increased plasma lipids, for example in liver disease or in splenectomy. 225 00:13:19.431 --> 00:13:22.601 Target cell can also be seen in hemoglobin C 226 00:13:22.735 --> 00:13:28.073 as That mutation actually introduces decreased solubility of hemoglobin. 227 00:13:28.340 --> 00:13:32.678 When you create a peripheral blood smear, this hemoglobin will be pulled 228 00:13:32.678 --> 00:13:35.681 to the central part of the red blood cell as it dries, 229 00:13:35.781 --> 00:13:38.784 creating this target cell appearance. 230 00:13:38.818 --> 00:13:41.687 Another cause of target cell formation is actually artifact. 231 00:13:41.687 --> 00:13:44.690 When the smears are dried to slowly. 232 00:13:47.026 --> 00:13:48.994 Sickle cell, 233 00:13:48.994 --> 00:13:51.630 as seen from its name, 234 00:13:51.630 --> 00:13:55.334 have a shape of a sickle, so by definition 235 00:13:55.334 --> 00:13:58.737 those are long and slender cells usually no central pallor. 236 00:13:59.004 --> 00:14:02.007 And they should have two pointed ends. 237 00:14:03.542 --> 00:14:06.846 In some situation they can look like crescents, for example this one. 238 00:14:07.313 --> 00:14:09.014 But it can also be shaped. 239 00:14:09.014 --> 00:14:12.017 They can be a little bit more elongated as opposed to curved. 240 00:14:12.751 --> 00:14:14.753 So the morphology can be quite variable. 241 00:14:14.753 --> 00:14:18.691 However, those cells are very important to be recognized as they represent 242 00:14:18.691 --> 00:14:22.695 a sickle cell anemia, quite a common, disease, 243 00:14:22.995 --> 00:14:25.965 especially in the African-American population. 244 00:14:25.965 --> 00:14:31.704 So sickle cell anemia is caused by mutation of the beta globin, chain gene. 245 00:14:32.671 --> 00:14:36.342 If an individual has only one mutated gene, 246 00:14:36.876 --> 00:14:41.013 so only one chromosome is affected, then this is what we call, hemoglobin. 247 00:14:41.013 --> 00:14:42.314 As trait. 248 00:14:42.314 --> 00:14:46.051 In this situation, patients do not present with sickle cells. 249 00:14:47.052 --> 00:14:50.923 Sickle cell anemia, alternatively, is when both of your chromosomes 250 00:14:51.223 --> 00:14:54.226 contain, mutated gene. 251 00:14:54.426 --> 00:14:57.830 So, the problem with hemoglobin S is that it 252 00:14:57.830 --> 00:15:00.833 tends to, polymerize, 253 00:15:00.866 --> 00:15:04.637 especially in this situation when the concentration of oxygen is low. 254 00:15:05.371 --> 00:15:08.941 So for patient with a hemoglobin S disease, the red blood 255 00:15:08.941 --> 00:15:12.645 cells that come from your bone marrow actually have normal morphology. 256 00:15:13.312 --> 00:15:16.749 But as those cells are exposed to hypoxia, for example, 257 00:15:16.749 --> 00:15:21.553 going through the kidney or perhaps, the patient is, going through some, 258 00:15:22.221 --> 00:15:25.224 hypoxic states, this hemoglobin will tend to, 259 00:15:25.724 --> 00:15:28.961 polymerize, changing the shape of the red blood cells. 260 00:15:29.728 --> 00:15:35.200 At first it is a, reversible process, but alternatively becomes irreversible. 261 00:15:35.467 --> 00:15:38.671 And as you see this deformed red blood cells become quite rigid. 262 00:15:38.904 --> 00:15:41.907 So it's really difficult for them to go through small capillaries. 263 00:15:41.974 --> 00:15:45.744 They will get stuck there causing very significant, painful, crises. 264 00:15:48.447 --> 00:15:49.648 So having discussed all those 265 00:15:49.648 --> 00:15:53.252 particular sites, let's also talk about how we report particular sites. 266 00:15:53.252 --> 00:15:56.622 So we need to make sure that there is reproducibility in the way 267 00:15:56.622 --> 00:16:00.392 we recognize those red blood cells in peripheral blood smears. 268 00:16:00.392 --> 00:16:05.030 And also give those changes correct grading. 269 00:16:05.531 --> 00:16:08.934 So there is a current recommendation of 270 00:16:09.301 --> 00:16:12.271 for standardization of reporting of particular sites. 271 00:16:12.771 --> 00:16:15.774 And I would, 272 00:16:16.208 --> 00:16:18.844 separate particular sites into different groups 273 00:16:18.844 --> 00:16:21.847 depending on the severity of their clinical significance. 274 00:16:23.449 --> 00:16:27.319 Such cells as bite cells and sickle cells, together with cheese. 275 00:16:27.353 --> 00:16:30.356 The sites are actually quite clinically significant. 276 00:16:30.456 --> 00:16:33.459 Therefore, when we call them moderate, 277 00:16:33.592 --> 00:16:38.197 unnecessary doses, the number of those diagnostic cells is way lower 278 00:16:38.797 --> 00:16:43.002 compared to the alternative group that includes spheroid sites of other 279 00:16:43.002 --> 00:16:48.107 sites, acanthus sites, a kind of sites, stomata sites and target cells. 280 00:16:48.707 --> 00:16:51.777 Those particular sites are also important, but, 281 00:16:52.411 --> 00:16:55.414 sometimes they can be seen in nonspecific situations. 282 00:16:55.614 --> 00:16:59.351 Therefore, let's say to report a moderate and there's a particular site ptosis. 283 00:16:59.518 --> 00:17:02.988 We need to have way higher number of those particular sites. 284 00:17:06.191 --> 00:17:09.194 So having said that, let's check our knowledge. 285 00:17:09.194 --> 00:17:13.465 The first challenge which of the particular sites are caused 286 00:17:13.832 --> 00:17:16.835 by decreased content to membrane ratio. 287 00:17:17.603 --> 00:17:21.240 So which of those cells are going to be seen when we have two low 288 00:17:21.240 --> 00:17:24.877 content in the red blood cells and two much of the membrane? 289 00:17:28.580 --> 00:17:31.483 The correct answer is target cell. 290 00:17:31.483 --> 00:17:34.920 So once again the target cells form when we have too little 291 00:17:34.920 --> 00:17:38.323 of your cytoplasmic content and too much of a membrane. 292 00:17:39.058 --> 00:17:41.660 The other alternatives would not be a correct answer. 293 00:17:41.660 --> 00:17:44.663 A sickle cell is because of hemoglobin S 294 00:17:45.531 --> 00:17:48.534 by cells, is because of unstable hemoglobin 295 00:17:48.934 --> 00:17:51.804 sphere sites is because you have an opposite problem 296 00:17:51.804 --> 00:17:54.873 when you have too much content and too little surface 297 00:17:54.873 --> 00:17:57.876 membrane. 298 00:17:58.510 --> 00:18:00.579 Challenge number two 299 00:18:00.579 --> 00:18:03.515 the transportation of this blood sample 300 00:18:03.515 --> 00:18:06.518 to the laboratory was significantly delayed. 301 00:18:07.219 --> 00:18:12.024 What type of particular sites will you most likely to see in the smear? 302 00:18:21.333 --> 00:18:24.036 The correct answer is a kind of site. 303 00:18:24.036 --> 00:18:27.873 We said that a kind of site A commonly seen in all specimens 304 00:18:28.774 --> 00:18:31.777 sphere sites, 305 00:18:31.777 --> 00:18:34.113 can be an artifact, but it's usually an artifact 306 00:18:34.113 --> 00:18:37.082 of the thin, part of the smear. 307 00:18:37.082 --> 00:18:40.886 A canter sites are not very commonly seen as an artifact, 308 00:18:41.253 --> 00:18:44.523 and target cells is usually an artifact of improper drying. 309 00:18:47.893 --> 00:18:49.628 And the last challenge 310 00:18:49.628 --> 00:18:53.232 when seen in low numbers from 2 to 5%, 311 00:18:53.899 --> 00:18:56.401 which particular site has a high clinical 312 00:18:56.401 --> 00:18:59.371 significance? 313 00:19:01.006 --> 00:19:04.009 The correct answer is sickle cell. 314 00:19:04.143 --> 00:19:07.646 According to the recommendations, the sickle cell thresholds 315 00:19:07.646 --> 00:19:11.416 for reporting and grading should be way lower than the target cells 316 00:19:11.717 --> 00:19:14.720 of other sites and similar sites. 317 00:19:16.054 --> 00:19:17.789 So today we'll learn about 318 00:19:17.789 --> 00:19:20.792 morphology of common particular sites. 319 00:19:21.593 --> 00:19:24.630 We also were able to discuss, 320 00:19:25.697 --> 00:19:26.231 the structure 321 00:19:26.231 --> 00:19:29.234 of the red blood cell membrane and some hemoglobin S. 322 00:19:29.334 --> 00:19:32.337 And we also recognize that not all particular sites are, 323 00:19:33.305 --> 00:19:35.574 equally significant. Thank you.