Haematology What is Haematology?

Haematology What is Haematology? The field of hematology covers a wide spectrum of disorders, ranging from acute leukemia to anemia. Some of these disorders are benign, meaning they resolve completely with therapy or do not cause symptoms and do not affect overall lifespan. Some are chronic, like acute leukemia, and lifelong but again do not affect longevity. Some examples of these benign disorders are: Anemia due to chronic disease Iron deficiency anemia Autoimmune hemolytic anemia, an immune-mediated disease causing a low red blood cell count Idiopathic thrombocytopenic purpura (ITP), an immune-mediated disease causing a low platelet count Low blood counts (white count, red cell count, or platelet count) due to a drug reaction-for example, heparin-induced thrombocytopenia Low blood counts not due to medications but related to underlying medical conditions-for example, anemia of chronic disease, or low platelet count secondary to liver disease Thalassemia (mild) Hemophilia (mild) Von Willebrand's disease Blood clots (not life-threatening) Monoclonal Gammopathy of Undetermined Significance ("MGUS"), a disorder of plasma cells causing abnormal proteins in the blood) Other disorders of the blood are more serious in that they can cause chronic illness or are life-threatening: Sickle cell anemia Hemophilia (severe) Recurrent blood clots (thrombophilia) Myelodysplastic syndrome Myeloproliferative diseases (characterized by excessive production of blood cells in the bone marrow): Polycythemia vera-too many red cells Essential thrombocythemia-too many platelets Primary myelofibrosis-excess fibrous or scar tissue in the marrow Chronic myelogenous leukemia (CML)-excessive white cell production causing leukemia Acute leukemia (including acute lymphocytic leukemia) Lymphocyte disorders: Chronic lymphocytic leukemia Lymphoma-Hodgkin's disease Lymphoma-non-Hodgkin's Plasma cell disorders: Multiple myeloma Waldenström's macroglobulinemia Heavy chain disease Another way to classify hematologic disease is whether it is inherited or acquired. For example, hemophilia, certain clotting disorders, thalassemia, and sickle cell anemia are inherited conditions, whereas most of the other disorders listed above are acquired. Inherited blood diseases are usually diagnosed in childhood, but if the individual is mildly affected, such a diagnosis may not be made until he/she reaches adulthood. For example, an abnormal laboratory finding may be discovered at the time of surgery when screening tests - an anemia or a clotting abnormality. These need to be evaluated to be sure the patient is not at increased risk for their operation. What are the symptoms? The symptoms of hematologic disease depend on many factors. Symptoms depend on which cell type is affected and how low or high the count. This is determined through a complete blood count ("CBC"). In anemia, there is a low number of red blood cells and therefore a decrease in oxygen delivered to tissues. Symptoms include: extreme fatigue, dizziness, loss of concentration, noise in the ear, shortness of breath with exertion, and fast heartbeat. In patients with impaired heart function, anemia can cause congestive heart failure. A low platelet count or thrombocytopenia can result in excessive bruising, red spots on the lower extremities, nose bleeds, bleeding from the mouth and gums, and blood in the urine or stools. Low numbers of white cells (leukopenia or neutropenia) can cause repeated bacterial infections. When a particular blood count is only mildly decreased, it may not cause any symptoms whatsoever. However, an abnormal count can be a marker of an underlying bone marrow disorder or other medical condition, and therefore should be investigated. A patient with liver disease, for example, may have a large spleen and low blood counts, particularly thrombocytopenia. The platelet count is usually not low enough to cause serious bleeding, but it should trigger an investigation as to why the spleen is enlarged, whether from cirrhosis of the liver and portal hypertension, Gaucher's disease, infection or lymphoma. Other systemic diseases have effects on iron metabolism causing chronic anemias (known as the anemia of chronic disease). They can also suppress bone marrow, as in systemic lupus erythematosis and other chronic inflammatory conditions. In these conditions, the signs and symptoms of the underlying disease are usually more pronounced than those related to low blood counts. Inherited disorders of hemoglobin, such as thalassemia and sickle cell anemia, cause a range of complications from mild to severe. In sickle cell disease, small blood vessels are sometimes blocked by red blood cells that have become deformed ("sickle"-shaped). Patients often have periodic pain episodes usually in the extremities and back, but occasionally in the abdomen. Although pain can be triggered by infection, surgery, weather changes, and even emotional stress, we usually don't know what triggers a particular pain crisis. No matter what the cause, sickle cell pain and other complications are incapacitating, and lead to frequent hospitalization. Just as inherited or acquired disorders can cause excessive bleeding, other inherited and acquired defects cause abnormal or excessive blood clotting. The coagulation system includes several important, naturally-occurring inhibitors of clotting, which if deficient or dysfunctional, lead to the formation of a blood clot. If the clot is in the veins just under the surface of the skin it's called a superficial thrombophlebitis. If it's in the deep venous system of the extremities, the diagnosis is a deep venous thrombosis or "DVT". This results in painful swelling of the extremity (usually the leg) associated with redness and increased skin temperature. If the blood clot is not treated immediately with blood thinning medication, there is an increased likelihood that a portion of the clot will break off and travel up through the right side of the heart and into the lung. This is known as a pulmonary embolism. The symptoms consist of sudden, sharp chest pain, shortness of breath, dizziness, palpitations, and coughing (sometimes coughing up blood). If the embolus is massive, sudden cardiovascular collapse and death can occur. Our clotting mechanism tends to become more active as we grow older, increasing the chances of having a DVT. Usually, there is some aggravating event that adds to a person's risk of thrombosis. This can include surgery, prolonged immobility (bed rest, long automobile or plane trips), smoking and estrogens (oral contraceptives, hormone replacement therapy). When these factors are absent, or when a younger patient presents with an unexplained DVT, an inherited tendency towards thrombosis (thrombophilia) is suspected. This suspicion is further bolstered by a positive family history of blood clots, history of frequent miscarriage, or a blood clot occurring in an unusual location, such as the blood vessels of the abdomen, venous channels of the brain, or blood vessels in the eye. In these circumstances a laboratory work-up is indicated to try and identify the defect in one or more of the inhibitory coagulation proteins. How is it diagnosed? A hematologist uses physical examinations, the patient's medical history and laboratory testing to assess hematological diseases. Whether the blood counts are too high or too low, one of the more common diagnostic dilemmas is separating a secondary or "reactive" phenomenon from a primary hematologic or bone marrow condition. Frequently a bone marrow biopsy will be needed for this purpose. This usually includes a study of the chromosomes (cytogenetics) and an examination of the surface proteins or receptors on the bone marrow cells (flow cytometry). The latter is a very sensitive test for ruling out a lymphoproliferative disorder, such as chronic lymphocytic leukemia or lymphoma. Other specialized testing is needed to rule out hemolysis or the rapid breakdown or destruction of red blood cells. Still further testing is required to look for the presence of organ problems (kidney, liver, lung, thyroid), connective tissue disorders (lupus erythematosis, rheumatoid arthritis), and cancer, all of which can have indirect effects on the bone marrow or blood. Diagnosing coagulation disorders can be relatively straightforward or difficult. Not infrequently, a patient will have bleeding symptoms, but even after extensive testing no abnormalities can be identified. This can be frustrating for both patient and physician, especially when deciding whether or not it's safe to proceed with surgery. This same scenario applies to disorders of excessive clotting, when patients have multiple episodes of thrombosis, yet no specific defect is uncovered after extensive testing. Despite these difficulties, coagulation medicine is an area of intense research and much progress has been made in just the last decade. What are the treatment options? Treatments vary depending on the type of disease, and can include simple observation, use of steroids and other immune-modulating therapies, transfusions or coagulation factor support, growth factor supplementation, complex chemotherapy and bone marrow transplantation. You should make an appointment with your physician at the leukemia hospital to discuss your treatment options. (See leukemia, myelodysplasia, lymphoma, bone marrow transplantation for more information.) Anemia If nutritional deficiencies are the cause, oral iron tablets, vitamin B12 injections, or and oral folic acid may be prescribed. For patients who have anemia due to autoantibodies against their own red cells (autoimmune hemolytic anemia), steroids suppress the immune system and interrupt red cell destruction. Prednisone given orally at moderately high doses is usually successful in slowing the process and increasing the hemoglobin level. However, steroids cannot be continued indefinitely without causing long-term side effects such as osteoporosis. The majority of patients respond, but in those who relapse, other agents such as intravenous immunoglobulin (IVIG), cyclophosphamide or cyclosporine are sometimes used. The spleen may need to be removed in some cases. Sickle cell anemia often is difficult to treat. If an underlying cause of a sickle cell crisis (such as infection) can be identified, prompt treatment will lessen the severity or duration of the crisis. The management of a severe pain episode requires potent pain-relieving narcotic medications. Transfusions are frequently given for severe anemia that compromises normal heart and lung function or when patients are going into surgery. They are also used in children and adults who have had strokes, since it's been demonstrated that regular transfusion or exchange transfusion prevents recurrence of stroke in patients with sickle cell disease. Unfortunately, chronic transfusion leads to problems with iron overload which results in the deposition of iron into the liver, heart and other sites, and this causes problems with those organs. We can use desferrioxamine or deferasirox (Exjade™) to help avoid these problems. Another drug, hydroxyurea, has been found to lessen the frequency and severity of sickle cell crises. Thrombocytopenia (low platelet count) Unlike anemia, there is no agent available that reliably increases the platelet count for conditions involving underproduction of platelets in the bone marrow. However, even a relatively low number of platelets may not require treatment because it does not cause life-threatening bleeding. In patients who have bone marrow conditions that result in severely low platelet counts or if severe thrombocytopenia and bleeding occur after chemotherapy, platelet transfusions must be given to either lessen the risk of bleeding or stop bleeding. Because transfused platelets do not last long in the circulation (average 3-4 days), and anti-platelet antibodies can develop upon repeated exposure to transfused or "foreign" cells, platelet transfusion is only used briefly to see the patient through a period of highest risk. Patients who have autoantibodies against platelets may develop severe thrombocytopenia (idiopathic thrombocytopenic purpura or ITP). This requires therapy to interrupt the destruction of platelets or to suppress the immune system. The first treatment usually consists of steroids, but other therapies such as intravenous immunoglobulin (IVIG), anti-Rh antibody (WinRhoSD ), and rituximab (Rituxan ) have been used successfully. Splenectomy is used in selected cases, resulting in long-term periods of remission of the disease. New agents are being developed for ITP, and we are participating in clinical trials to test new medications. Another disorder causing severe thrombocytopenia is thrombotic thrombocytopenic purpura or TTP. TTP is an acute illness affecting multiple organ systems. TTP causes platelets to aggregate and obstruct blood flow in small arterial vessels. This leads to neurological and kidney dysfunction as well as a type of anemia called microangiopathic hemolytic anemia. TTP is treated by exchanging the patient's own plasma for new plasma. Plasma exchange is usually available only in referral centers that have the sophisticated equipment and trained personnel required to perform this procedure in a safe and expeditious manner. (Myeloproliferative diseases-polycythemia vera, essential thrombocythemia, and primary myelofibrosis) Myeloproliferative disorders all result in the overproduction of blood cells. Because of the detrimental effects of high numbers of blood cells of all types, treatment is directed towards lowering their numbers. Polycythemia vera is treated with phlebotomy, a simple technique that involves removal of units of blood at appropriate intervals. This keeps the red cell count (hematocrit) within the normal range, lessening the risk of stroke or heart attack. In essential thrombocythemia, and in some cases of polycythemia vera, the high platelet count needs to be lowered, also to prevent stroke, heart attack, or life-threatening blood clotting. The optimal platelet count in this situation is unknown, largely because the degree of platelet activation, and therefore increased potential for clotting, cannot be routinely measured. Generally, however, a count of 600,000/ l (normal: 150,000 to 450,000/ l) is used as a threshold for initiating therapy in myeloproliferative diseases. If the patient is experiencing a life-threatening thrombotic event, the platelet count can be brought down very rapidly by mechanical means (plateletpheresis). Otherwise, medications, either hydroxyurea or anagrelide (Agrylin™), are used. Both of these drugs suppress the bone marrow cells that make platelets (megakaryocytes) and platelet production, although hydroxyurea has a more global effect on bone marrow function. Coagulation disorders (excess bleeding or clotting) Severe inherited bleeding disorders usually come to light in childhood, when parents observe excessive bleeding with mild or no obvious cause. If the diagnosis is hemophilia, therapy is directed toward replacing the clotting factor that's missing. With the range of factor VIII and IX concentrates available today, either purified from human plasma or produced by molecular techniques (recombinant), this is a relatively straightforward process. There are, however, several caveats to be taken into account. First, the dosage has to calculated correctly and adjusted for the type of bleeding episode. Second, patients or their parents must be taught to administer the factor at home, since prompt administration after a bleed into a joint or soft tissue limits the total amount of bleeding and prevents further tissue damage. Third, some patients develop inhibitors (antibodies) to the infused factor product. This greatly complicates the management of a bleeding episode since the antibody acts to immediately neutralize the activity of the transfused factor. In such cases other types of factor products that bypass the block imposed by the inhibitor are used to treat bleeding. Fourth, the management of patients with hemophilia should be undertaken only by hematologists and surgeons well versed in the disease and its complications and familiar with the wide assortment of clotting factor products available. In mild forms of hemophilia and in most types of von Willebrand's disease, the disorder is often not diagnosed until adulthood, when the individual has a pre-operative assessment for elective surgery that shows abnormal clotting times. Usually the surgery has to be delayed and the abnormality assessed by a hematologist. If an underlying abnormality is found, the patient is then given a test dose of DDAVP (Desmopressin), which causes an increase in FVIII or von Willebrand's factor levels. If enough of an increase is demonstrated, then this agent can be used to support hemostasis during a minor surgical procedure. If not, or if it is a major operation (cardiac or brain surgery), FVIII or von Willebrand's factor concentrates must be given immediately before the procedure and continued for several days afterwards. Certain thrombotic (blood clotting) diseases are also inherited, but usually don't manifest themselves until later in life. Some clots can occur spontaneously and without obvious cause, but more common is the type of blood clot that develops after surgery or prolonged periods of immobility. No matter what the setting, the treatment is anticoagulant therapy. After certain types of surgery, such as orthopedic procedures on the lower extremities, or surgery on the spine, the risk of postoperative thrombosis is very high. Multiple clinical trials have demonstrated the benefit of giving prophylactic anticoagulation to reduce the incidence of thrombotic events. Either heparin or warfarin is used, starting as soon as feasible after the operation and continuing until the patient is ambulatory. Anticoagulants also are used to treat an already established blood clot. Therapy consists of intravenous heparin, followed by oral warfarin (Coumadin ). In uncomplicated thrombosis, the patient may be able to self-administer medications at home. Usually anticoagulant therapy is continued for 3 to 6 months. Patients who have recurrent episodes of thrombosis, especially pulmonary emboli, or who have laboratory markers of thrombophilia, usually receive longer and occasionally indefinite periods of treatment. The field of hematology comprises a broad spectrum of disorders of the blood and bone marrow. Because problems in other organs often affect the blood, deciding whether a blood abnormality is secondary to some other illness or a primary disorder in and of itself can be a very complex and sometimes irresolvable issue. Sophisticated coagulation and hematology laboratory tests, plus the input of other medical specialists, are often required to make the correct diagnosis and rational treatment decisions. Ongoing basic science and clinical research studies in hematology have improved our understanding of the pathophysiology of blood and coagulation diseases and improved our diagnostic tools. Such research holds the promise of new therapeutic agents to treat our patients, improving their overall outcome and quality of life.

COMMON SYMPTOMS OF LEUKEMIA

LEUKEMIA- Common Symptoms Common Symptoms of Chronic Leukemia or Acute Leukemia Swollen lymph nodes (especially in the neck or armpit) that can be painful. Lymph nodes are the regions where blood cleanses itself and can drain the excess leukemic cells in these regions. This will result in swelling and inflammation and makes these lymph nodes prone to infections and lymphitis. Fevers or night sweats Frequent infections – this is because the number of increased white blood cells are immature and do not have the ability to fight bacterial and viral infections efficiently as under normal conditions. The accumulation of these immature white blood cells in the bone marrow will also result in reduction of bone marrow cells required for the synthesis of blood platelets. Hence, there will be excessive bleeding or development of pinprick bleeding (petechiae) due to a disturbance in the blood clotting process resulting in malformed blood clots, and thus one can frequently see purple patches of blood clots. Feeling weak or tired Bleeding and bruising easily (bleeding gums, purplish patches in the skin, or tiny red spots under the skin Swelling or discomfort in the abdomen causing pain that may result in loss of appetite and weight Weight loss for no reason Pain in the bones and joints because of cell proliferation in the bone marrow Unexplained fevers Blurred vision Balance problems Shortness of breath or dyspnea when the cells accumulate in the chest resulting in pain and difficulty in breathing seeking immediate medical attention Loss of muscle control and seizures Anemia – there will be reduction in the number of red blood cells and platelets and hence will there be a reduction in the possibility of ability to carry oxygen leading to a number of other related symptoms. However, common are these symptoms for other infections also and so only, a doctor can tell for sure what is what. The good thing about leukemia is that a simple blood test could be able to help you to diagnose and respond appropriately. The difference between acute and chronic leukemia is that in chronic leukemia the symptoms do not appear until the disease is diagnosed until the later stages after development of cancer in the blood while in acute leukemia the symptoms are diagnosed immediately and easily.

LEUKEMIA AND SOLUTIONS

LEUKEMIA The word Leukemia comes from the Greekleukos which means "white" and aima which means "blood". It is CANCER of the blood or bone marrow (which produces blood cells). A person who has leukemia suffers from an abnormal production of blood cells, generally leukocytes (white blood cells). The DNA of immature blood cells, mainly white cells, becomes damaged in some way. This abnormality causes the blood cells to grow and divide chaotically. Normal blood cells die after a while and are replaced by new cells which are produced in the bone marrow. The abnormal blood cells do not die so easily, and accumulate, occupying more and more space. As more and more space is occupied by these faulty blood cells there is less and less space for the normal cells - and the sufferer becomes ill. Quite simply, the bad cells crowd out the good cells in the blood. In order to better understand what goes on we need to have a look at what the bone marrow does. Function of the bone marrow The bone marrow is found in the inside of bones. The marrow in the large bones of adults produces blood cells. Approximately 4% of our total bodyweight consists of bone marrow. There are two types of bone marrow: 1. Red marrow, made up mainly of myeloid tissue. 2. Yellow marrow, made up mostly of fat cells. Red marrow can be found in the flat bones, such as the breast bone, skull, vertebrae, shoulder blades, hip bone and ribs. Red marrow can also be found at the ends of long bones, such as the humerus and femur. White blood cells (lymphocytes), red blood cells and platelets are produced in the red marrow. Red blood cells carry oxygen, white blood cells fight diseases. Platelets are essential for blood clotting. Yellow marrow can be found in the inside of the middle section of long bones. If a person loses a lot of blood the body can convert yellow marrow to red marrow in order to raise blood cell production. White blood cells, red blood cells and platelets exist in plasma - Blood plasma is the liquid component of blood, in which the blood cells are suspended. Types of leukemia Chronic and Acute Experts divide leukemia into four large groups, each of which can be Acute, which is a rapidly progressing disease that results in the accumulation of immature, useless cells in the marrow and blood, or Chronic, which progresses more slowly and allows more mature, useful cells to be made. In other words, acute leukemia crowds out the good cells more quickly than chronicleukemia. Lymphocytic and Myelogenous Leukemias are also subdivided into the type of affected blood cell. If the cancerous transformation occurs in the type of marrow that makes lymphocytes, the disease is calledlymphocytic leukemia. A lymphocyte is a kind of white blood cell inside your vertebrae immune system. If the cancerous change occurs in the type of marrow cells that go on to produce red blood cells, other types of white cells, and platelets, the disease is called myelogenous leukemia. To recap, there are two groups of two groups - four main types of leukemia, as you can see in the illustration below: ACUTE LYMPHOCYTIC LEUKEMIA(ALL)also known as Acute Lymphoblastic Leukemia - This is the most common type of leukemia among young children, although adults can get it as well, especially those over the age of 65. Survival rates of at least five years range from 85% among children and 50% among adults. The following are all subtypes of this leukemia: precursor B-ACUTE LYMPHOBLASTIC LEUKEMIA precursor T acute lymphoblastic leukemia, Burkitt's leukemia, and acute biphenotypic leukemia. Chronic Lymphocytic Leukemia (CLL) - This is most common among adults over 55, although younger adults can get it as well. CLL hardly ever affects children. The majority of patients with CLL are men, over 60%. 75% of treated CLL patients survive for over five years. Experts say CLL is incurable. A more aggressive form of CLL is B-cell prolymphocytic leukemia. ACUTE MYELOGENOUS LEUKEMIA(AML) - AML is more common among adults than children, and affects males significantly more often than females. Patients are treated with chemotherapy. 40% of treated patients survive for over 5 years. The following are subtypes of AMS - acute promyelocytic leukemia, acute myeloblastic leukemia, and acute megakaryoblastic leukemia. Chronic Myelogenous Leukemia (CML) - The vast majority of patients are adults. 90% of treated patients survive for over 5 years. Gleevc (imatinib) is commonly used to treat CML, as well as some other drugs. Chronic monocytic leukemia is a subtype of CML. Symptoms of leukemia Blood clotting is poor - As immature white blood cells crowd out blood platelets, which are crucial for blood clotting, the patient may bruise or bleed easily and heal slowly - he may also develop petechiae (a small red to purple spot on the body, caused by a minor hemorrhage). Affected immune system - The patient's white blood cells, which are crucial for fighting off infection, may be suppressed or not working properly. The patient may experience frequent infections, or his immune system may attack other good body cells. Anemia - As the shortage of good red blood cells grows the patient may suffer from anemia- this may lead to difficult or labored respiration (dyspnea) and pallor (skin has a pale color caused by illness). Other symptoms - Patients may also experience nausea, fever, chills, night sweats, flu-like symptoms, and tiredness. If the liver or spleen becomes enlarged the patient may feel full and will eat less, resulting in weight loss. headache is more common among patients whose cancerous cells have invaded the CNS (central nervous system). Precaution - As all these symptoms could be due to other illnesses. A diagnosis of leukemia can only be confirmed after medical tests are carried out. What causes leukemia? Experts say that different leukemias have different causes. The following are either known causes, or strongly suspected causes: Artificial ionizing radiation Viruses - HTLV-1 (human T-lymphotropic virus) and HIV (human immunodeficiency virus) Benzene and some petrochemicals Alkylating chemotherapy agents used in previous cancers Maternal fetal transmission (rare) Hair dyes Genetic predisposition - some studies researching family history and looking at twins have indicated that some people have a higher risk of developing leukemia because of a single gene or multiple genes. Down Syndrome - people with Down syndrome have a significantly higher risk of developing leukemia, compared to people who do not have Down syndrome. Experts say that because of this, people with certain chromosomal abnormalities may have a higher risk. Electromagnetic energy - studies indicate there is not enough evidence to show that ELF magnetic (not electric) fields that exist currently might cause leukemia. The IARC (International Agency for Research on Cancer) says that studies which indicate there is a risk tend to be biased and unreliable. Treatments for leukemia As the various types of leukemias affect patients differently, their treatments depend on what type of leukemia they have. The type of treatment will also depend on the patient's age and his state of health. In order to get the most effective treatment the patient should get treatment at a center where doctors have experience and are well trained in treating leukemia patients. As treatment has improved, the aim of virtually all health care professionals should be complete remission - that the cancer goes away completely for a minimum of five years after treatment. Treatment for patients with acute leukemias should start as soon as possible - this usually involves induction therapy with chemotherapy, and takes place in a hospital. When a patient is in remission he will still need consolidation therapy or post induction therapy. This may involve chemotherapy, as well as a bone marrow transplant (allogeneic stem cell transplantation). If a patient has Chronic Myelogenous Leukemia (CML) his treatment should start as soon as the diagnosis is confirmed. He will be given a drug, probably Gleevec (imatinib mesylate), which blocks the BCR-ABL cancer gene. Gleevec stops the CML from getting worse, but does not cure it. There are other drugs, such as Sprycel (dasatinib) and Tarigna (nilotinb), which also block the BCR-ABL cancer gene. Patients who have not had success with Gleevec are usually given Sprycel and Tarigna. All three drugs are taken orally. A bone marrow transplant is the only current way of curing a patient with CML. The younger the patient is the more likely the transplant will be successful. Patients with Chronic Lymphocytic Leukemia (CLL) may not receive any treatment for a long time after diagnosis. Those who do will normally be given chemotherapy or monoclonal antibody therapy. Some patients with CLL may benefit from allogeneic stem cell transplantation (bone marrow transplant). All leukemia patients, regardless of what type they have or had, will need to be checked regularly by their doctors after the cancer has gone (in remission). They will undergo exams and blood tests. The doctors will occasionally test their bone marrow. As time passes and the patient continues to remain free of leukemia the doctor may decide to lengthen the intervals between tests. How common is leukemia? According to the Leukemia and Lymphoma Society, there were approximately 13,410 new cases of AML (2007), 5,200 new cases of ACL (2007), 4,570 cases of CML (2007), and 15,110 new cases of CLL (2008) diagnosed in the USA. What is the difference between Leukemia and Lymphoma? Leukemia is a cancer of the blood. Lymphoma is of the lymphatic system (lymph glands).

വാഹനത്തിന്റെ ഇന്ധനം ലാഭിക്കാന്‍ ചില മാര്‍ഗങ്ങള്‍..

ഒരു വാഹനം വാങ്ങിക്കഴിഞ്ഞാല്‍ കമ്പനി അവകാശപ്പെടുന്ന മൈലേജ്‌ പലപ്പോഴും ലഭിക്കാറില്ലെന്ന്‌ പരാതി പറയുന്നവരാണ്‌ കൂടുതല്‍ ഉപഭോക്‌താക്കളും. എന്താണ്‌ ഇതിന്‌ കാരണം? കമ്പനി പറയുന്ന മൈലേജ്‌ ലഭിക്കണമെങ്കില്‍, വാഹനം ഓടുന്നത്‌ നല്ല റോഡിലൂടെയാകണം. വാഹനത്തിന്‌ ശ്രദ്ധയോടെയുള്ള പരിചരണവും ആവശ്യമാണ്‌. ചില കാര്യങ്ങള്‍ ശ്രദ്ധിച്ചാല്‍ ഇന്ധനം പാഴായി പോകുന്നത്‌ ഒഴിവാക്കാനാകും.

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ക്‌ളച്ച്‌ അമിതമായി ഉപയോഗിച്ച്‌ വണ്ടിയോടിക്കുന്നത്‌ ചിലരുടെ ശീലമാണ്‌. ട്രാന്‍സ്‌മിഷന്‍ പ്രവത്തനത്തെ തടഞ്ഞുകൊണ്ടു വാഹനം നിയന്ത്രിക്കപ്പെടുകയാണ്‌ ഇതിലൂടെ സംഭവിക്കുന്നത്‌. ഇതുവഴി അമിതമായി ഇന്ധനം കത്തിപ്പോകുകയും ചെയ്യുന്നു. അതുകൊണ്ട്‌ ഡ്രൈവ്‌ ചെയ്യുമ്പോള്‍ ആവശ്യമില്ലാതെ ക്‌ളച്ച്‌ ഉപയോഗിക്കരുത്‌.

അമിതവേഗം വേണ്ട...

വാഹനം ഒരു ശരാശരി വേഗതയില്‍ ഓടിക്കുന്നതാണ്‌ എപ്പോഴും നല്ലത്‌. അമിതവേഗത ഇന്ധനം പാഴാക്കുക മാത്രമാണ്‌ ചെയ്യുന്നത്‌. വേഗതയ്‌ക്കനുസരിച്ച്‌ എല്ലാ ഗിയറുകളും മാറി ശരാശരി വേഗത്തില്‍ ഡ്രൈവ്‌ ചെയ്യുന്നതാണ്‌ ഉത്തമം.

ട്രാഫിക്കില്‍ എന്‍ജിന്‍ ഓഫ്‌ ചെയ്യുക...

ട്രാഫിക്‌ സിഗ്‌നലിനായി ഒരുപാട്‌ നേരം കാത്തുകിടക്കുന്ന അവസരത്തില്‍ എന്‍ജിന്‍ ഓഫ്‌ ചെയ്യുക. പല സ്ഥലങ്ങളിലും ട്രാഫിക്‌ സിഗ്‌നലിനായി കൗണ്ട്‌ ഡൗണ്‍ ഉണ്ടാകും. ഇതു മനസിലാക്കി എന്‍ജിന്‍ ഓഫ്‌ ചെയ്യുന്നതാണ്‌ നല്ലത്‌. കൗണ്ട്‌ ഡൗണ്‍ അവസാനിക്കുമ്പോള്‍ എന്‍ജിന്‍ ഓണാക്കാം. ഇതുവഴി ഇന്ധനം ലാഭിക്കാനാകും.

ഗിയര്‍ മാറ്റുന്നത്‌ ശ്രദ്ധയോടെ...

ഗിയറാണ്‌ വാഹനത്തിന്റെ ചലനത്തെ നിയന്ത്രിക്കുന്നത്‌. വാഹനം ചലിയ്‌ക്കുന്നതിന്‌ അനുസരിച്ച്‌ ഗിയര്‍ മാറ്റണം. സമയാസമയം ഗിയര്‍ മാറ്റുന്നതിലൂടെ ഇന്ധനം ലാഭിക്കാനാകും. അതായത്‌, ഇപ്പോള്‍ പുറത്തിറങ്ങുന്ന ന്യൂ ജനറേഷന്‍ വാഹനങ്ങള്‍ പെട്ടെന്ന്‌ ചലിപ്പിച്ച്‌ എല്ലാ ഗിയറുകളും മാറിയാല്‍ മാത്രമെ കമ്പനി അവകാശപ്പെടുന്ന മൈലേജ്‌ ലഭിക്കുകയുള്ളു. കുറഞ്ഞ ഗിയറുകളില്‍ കൂടുതല്‍ ദൂരം വാഹനം ഓടിക്കുന്നത്‌, ഇന്ധനം കത്തിക്കാന്‍ മാത്രമെ ഉപകരിക്കൂ...

മികച്ച ഡ്രൈവിംഗ്‌......

ചിലര്‍ വാഹനം ഓടിക്കുന്നത്‌ കണ്ടിട്ടില്ലേ? അനാവശ്യമായി വേഗം കുറച്ചും കൂട്ടിയുമൊക്കെ. ഇത്‌ വാഹനത്തിന്റെ യന്ത്രത്തകരാറിന്‌ ഇടയാക്കുകയും മൈലേജ്‌ കുറയ്‌ക്കുകയും ചെയ്യും. റോഡിന്റെ പരിതസ്ഥിയും ട്രാഫികും കണക്കിലെടുത്ത്‌, വേഗത ക്രമീകരിച്ച്‌ വേണം ഡ്രൈവ്‌ ചെയ്യേണ്ടത്‌. ഇതിലൂടെ ഇന്ധനം ലാഭിക്കാനുമാകും.

പെട്ടെന്നുള്ള ബ്രേക്കിംഗ്‌ വേണ്ട...

മുമ്പിലുള്ള വാഹനവുമായി ക്രമമായ അകലം പാലിക്കുക. അമിത വേഗത ഒഴിവാക്കുക. ഇതിലൂടെ സഡന്‍ ബ്രേക്കിംഗ്‌ ഒഴിവാക്കാം. വളരെ വേഗതയില്‍ പോകുന്ന വാഹനം പെട്ടെന്ന്‌ ബ്രേക്ക്‌ ചെയ്യുന്ന അവസ്ഥയുണ്ടായാല്‍ ഇന്ധനം വെറുതെ കത്തിപ്പോകും. എപ്പോഴും ശ്രദ്ധയോടെ വാഹനം ഡ്രൈവ്‌ ചെയ്‌താല്‍ പെട്ടെന്നുള്ള ബ്രേക്കിംഗ്‌ ഒഴിവാക്കാന്‍ സാധിക്കും.

mullaperiyar

ചെന്നൈ: പുതിയ അണക്കെട്ട് നിര്‍മിക്കാനുള്ള തീരുമാനത്തില്‍ നിന്ന് പിന്‍വാങ്ങാന്‍ കേരളത്തെ ഉപദേശിക്കണമെന്ന് തമിഴ്നാട് മുഖ്യമന്ത്രി ജയലളിത പ്രധാനമന്ത്രി മന്‍മോഹന്‍ സിങ്ങിനോട് ആവശ്യപ്പെട്ടു. രണ്ട് ദിവസത്തെ തമിഴ്നാട് സന്ദര്‍ശനത്തിനായെത്തിയ പ്രധാനമന്ത്രിയുമായി രാജ്ഭവനില്‍ നടത്തിയ കൂടിക്കാഴ്ചക്കിടയിലാണ് ജയലളിത ആവശ്യമുന്നയിച്ചത്.

മുല്ലപ്പെരിയാര്‍ വിഷയത്തിലും കൂടംകുളം ആണവപദ്ധതിയുടെ കാര്യത്തിലും ഇരുവരും ചര്‍ച്ച നടത്തി. കൂടിക്കാഴ്ച 40 മിനുട്ട് നീണ്ടുനിന്നു.

മുല്ലപ്പെരിയാര്‍ അണക്കെട്ടിന്റെ സുരക്ഷയുമായി ബന്ധപ്പെട്ട് കേന്ദ്രസേനയെ വിന്യസിക്കണമെന്ന ആവശ്യം അവര്‍ ആവര്‍ത്തിച്ചു. കേരള സര്‍ക്കാര്‍ ജനങ്ങളില്‍ ഭയം സൃഷ്ടിക്കുകയാണെന്നും ഇത് തമിഴ്നാടിന് നേരെ അക്രമമുണ്ടാകാനിടയാക്കുന്നുവെന്നും അവര്‍ കുറ്റപ്പെടുത്തി. പ്രശ്നത്തിന് ഇരുസംസ്ഥാനങ്ങളും ചര്‍ച്ച ചെയ്ത് പരിഹാരം കാണണമെന്ന് പ്രധാനമന്ത്രി ജയലളിതയോട് ആവശ്യപ്പെട്ടെന്നാണ് സൂചന.

മുല്ലപ്പെരിയാറടക്കം ആറ് വിഷയങ്ങളില്‍ ജയലളിത പ്രധാനമന്ത്രിക്ക് നിവേദനം നല്‍കി. കൂടിക്കാഴ്ചയ്ക്ക് ശേഷം മാധ്യമപ്രവര്‍ത്തകരുമായി സംസാരിക്കാന്‍ ജയലളിത തയാറായില്ല.

അധ്യാപകനും ദുരന്തവും

  അധ്യാപകനും ദുരന്തവും 

 

ഒരു ഹൈസ്കൂള്‍ ക്ലാസ്സ്‌. അധ്യാപകന്‍ കുട്ടികളോട് ഒരു ട്രെയിന്‍ ദുരന്തത്തെ കുറിച്ച് പറയവേ എന്താണ് ദുരന്തവും അപകടവും തമ്മിലുള്ള വ്യത്യാസം എന്ന് ചോദിച്ചു.ഒരു കുട്ടി എണീറ്റ്‌ പറഞ്ഞു.മാഷ് ഒരു പാലത്തില്‍ നിന്നും പുഴയിലേക്ക് വീണാല്‍ അത് അപകടം.അവിടെ നിന്ന് മാഷ് രക്ഷപ്പെട്ടു ഈ ക്ലാസ്സിലേക്ക് വീണ്ടും വന്നാല്‍ അത് ദുരന്തം.ഒരു തമാശയാണ്.....പക്ഷെ ഇത്തരം അധ്യാപകരില്ലേ?

Mullaperiyar V/s Piravam

പിറവം ഉപ തിരഞ്ഞെടുപ്പിന് മുന്ബുള്ള മുല്ലപെരിയാര്‍ പരിശീലന മത്സരങ്ങള്‍ മാറ്റി വെച്ചു.തിരഞ്ഞെടുപ്പ് കമ്മീഷന്‍ പിറവം തിരഞ്ഞെടുപ്പ് പ്രഘ്യപിക്കുന്നത് വരെ മുല്ലപെരിയാര്‍ പരിശീലന മത്സരങ്ങളില്‍ നിന്ന് മാറി നില്ക്കാന്‍ കേരളത്തിലെ എല്ലാ കളിക്കാരും ധാരണയിലെത്തി.അത് വരെ ജനത്തെ വിദ്ടിയാക്കുന്നത്‌ തല്ക്കാലം നിര്‍ത്തി വെക്കനമെന്നാണ് തല്ക്ക്കലമുണ്ടായ ധാരണ.മുല്ലപ്പെരിയാര്‍ പ്രദേശത്ത് ഡിസംബര്‍ മാസമായത് കൊണ്ടുള്ള തണുപ്പും,മലയാളികളെ തിരഞ്ഞു പിടിച്ചു ക്യ്കാര്യം ചെയ്യുന്ന തമിഴരുടെ ചെയ്തികളും, മാണി, ജോസെഫ്,ഉമ്മന്‍ ചാണ്ടി എന്ന്നിവരുടെ തിരക്കും,അപ്പുറത്ത് വി എസും, പിണറായിയും തറവാട് പിടിക്കാനുള്ള മത്സരവും നടക്കുന്നതിനാലാണ് ഇപ്പോഴുണ്ടായ താല്‍ക്കാലിക ധാരണ.എന്നാല്‍ ഒരൊറ്റ പീറ രാഷ്ട്രീയക്കാരനും ഇനി മുല്ലപെരിയാര്‍ ഗ്രൗണ്ടില്‍ വന്നു പന്ത് തട്ടില്ലെന്നു അവിടുത്തെ പത്തോളം പഞ്ചായത്തുകളിലെ താമസക്കാരും പ്രഘ്യാപിച്ചതോടെ പിറവം ഗ്രൗണ്ടില്‍ പഴയ കളി(മുല്ലപെരിയാര്‍) വേണ്ടെന്നു വെക്കുന്നതാവും നല്ലതെന്ന് കേരള കളിക്കാര്‍ക്കെല്ലാം ബോധ്യപ്പെട്ടിട്ടുണ്ട്.അതിനിടെ വി എസിന്റെ പുതിയ എരിവുള്ള പ്രസ്താവനയുമായി ഒരാഴ്ച കഞ്ഞി കുടിക്കാമെന്ന് കേരളത്തിലെ ചാനെല്‍ മുതലാളിമാരും തീരുമാനിച്ചു '''''''കൊച്ചി: പാര്‍ട്ടി സമ്മേളനങ്ങളില്‍ അനുവദിച്ചിട്ടുള്ള ജനാധിപത്യ സംവിധാനം ഉപയോഗിച്ച് സത്യസന്ധമായി പ്രവര്‍ത്തിക്കുന്നവരെ തകര്‍ക്കാന്‍ ചില വക്രന്മാര്‍ ശ്രമിക്കുന്നതായി വി.എസ്. അച്യുതാനന്ദന്‍. കാലങ്ങളായി നിലനില്‍ക്കുന്ന സാമ്പ്രദായങ്ങളെ മാറ്റാന്‍ ജനാധിപത്യപരമായ അവകാശം വിനിയോഗിക്കാന്‍ പാര്‍ട്ടി അനുവദിക്കുന്നുണ്ട്. എന്നാല്‍, ഇതിന്റെ മറവില്‍ സത്യസന്ധമായി പ്രവര്‍ത്തിക്കുന്നവരെ തകര്‍ക്കാന്‍ ശ്രമിക്കുന്നു. ഇത് പ്രത്യേകമായി പരിശോധിക്കണമെന്ന് വി.എസ് കൊച്ചിയില്‍ മാധ്യമ പ്രവര്‍ത്തകരോട് പറഞ്ഞു''''''''''തമിഴന്മാര്‍ മലയാളികളെ മൂക്കിനു തോണ്ടുന്നത്‌(ചമ്മന്തി)കൊണ്ട് മാത്രം കഞ്ഞി കുടിച്ചു കഴിഞ്ഞിരുന്ന ചാനെല്‍ ബൂര്‍ഷകള്‍ക്ക് വി എസിന്റെ പുതിയ സെല്‍ഫ് ഗോള്‍ നന്നേ പിടിച്ചു.ഇനി കാരാട്ട് രഫെറി വന്നു പിണറായിക്ക് പെനാല്‍ടി കൊടുക്കുമോ,അതോ പിണറായി മുന്നേറി വി എസ് പോസ്റ്റില്‍ ഗോളുകള്‍ നിറക്കുമോ എന്ന ചര്‍ച്ചകലാവും ഒരാഴ്ച ചാനലുകളില്‍ ഉണ്ടാവുകയെന്ന് ടി വി കാണികളുടെ സംഘടന അറിയിച്ചു.വിനോദം ആവശ്യമുള്ളവര്‍ക്ക് സൂര്യ ടി വി യിലെ അടി അല്ലേല്‍ നോ അടി/ഇടി അല്ലേല്‍ നോ ഇടി,....
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