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Abstract
Now over 70,000 copies sold!
This comprehensively revised edition of Clinical Biochemistry offers essential reading for today’s students of medicine and other health science disciplines – indeed, anyone who requires a concise, practical introduction to the subject. Topics are clearly presented in a series of double-page ‘learning units’, each covering a particular aspect of clinical biochemistry. Four sections provide a core grounding in the subject:
- Introducing clinical biochemistry gives an insight into how modern hospital laboratories work, and includes an entirely new series of learning units on the interpretation of test results
- Core biochemistry covers the bulk of routine analyses, and their relevance to the clinical setting
- Endocrinology provides an overview of endocrine investigations as well as a practical approach to thyroid, adrenal, pituitary and gonadal function testing
- Specialised investigations embraces an assortment of other topics that students may encounter
This edition represents the most radical revision of the book to date. Every learning unit has been examined and updated to reflect current developments and clinical best practice. Entirely new material includes a series of learning units on interpretation and analytical aspects of clinical biochemistry. Coverage of fluid biochemistry is now more comprehensive. New "Want to know more?" links throughout the book point readers to relevant further information.
- (Printed version) now includes the complete eBook version for the first time – downloadable for anytime access and enhanced with new, interactive multiple choice questions for each section, to test your understanding and aid exam preparation
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | cover | ||
| Inside Front Cover | ifc1 | ||
| Clinical Biochemistry | i | ||
| Copyright Page | iv | ||
| Preface | v | ||
| Acknowledgements | vi | ||
| Table Of Contents | vii | ||
| 1 Introducing clinical biochemistry | 1 | ||
| 1 The clinical biochemistry laboratory | 2 | ||
| The use of biochemical tests | 2 | ||
| Core biochemistry | 2 | ||
| Specialised tests | 2 | ||
| Urgent samples | 2 | ||
| Automation and computerisation | 3 | ||
| Test repertoire | 3 | ||
| Laboratory personnel | 3 | ||
| 2 The use of the laboratory | 4 | ||
| Specimen collection | 4 | ||
| Blood specimens | 4 | ||
| Urine specimens | 4 | ||
| High-risk specimens | 4 | ||
| Sampling errors | 4 | ||
| Analysing the specimen | 5 | ||
| Timing | 5 | ||
| Unnecessary testing | 5 | ||
| 3 Interpretation of results | 6 | ||
| How biochemical results are expressed | 6 | ||
| Units | 6 | ||
| Reference intervals | 6 | ||
| Biological factors affecting ‘normality’ | 6 | ||
| Health versus disease | 7 | ||
| 4 Interpretation of results | 8 | ||
| Diagnostic test outcomes | 8 | ||
| The impact of prevalence on test utility | 8 | ||
| Final thoughts | 9 | ||
| 5 Interpretation of results | 10 | ||
| Sources of variation | 10 | ||
| Pre-analytical variation | 10 | ||
| Analytical variation | 10 | ||
| Biological variation | 10 | ||
| Other biological variation | 10 | ||
| 6 Analytical aspects | 12 | ||
| Precision and accuracy | 12 | ||
| Analytical sensitivity and specificity | 12 | ||
| Quality assurance | 12 | ||
| 2 Core biochemistry | 13 | ||
| 7 Fluid and electrolytes | 14 | ||
| Body fluid compartments | 14 | ||
| Evaluation of hydration | 14 | ||
| Osmolality | 15 | ||
| Oncotic pressure | 15 | ||
| 8 Water and sodium balance | 16 | ||
| Water | 16 | ||
| AVP and the regulation of osmolality | 16 | ||
| Sodium | 16 | ||
| Aldosterone | 17 | ||
| Atrial natriuretic peptide | 17 | ||
| Regulation of volume | 17 | ||
| 9 Hyponatraemia | 18 | ||
| Mechanisms of hyponatraemia | 18 | ||
| Water retention | 18 | ||
| Sodium loss | 18 | ||
| Sodium depletion – a word of caution | 19 | ||
| Pseudohyponatraemia | 19 | ||
| 10 Hyponatraemia | 20 | ||
| Clinical assessment | 20 | ||
| Severity | 20 | ||
| Mechanism | 20 | ||
| History | 20 | ||
| Clinical examination | 20 | ||
| Biochemistry | 20 | ||
| Oedema | 20 | ||
| Treatment | 21 | ||
| 11 Hypernatraemia | 22 | ||
| Water loss | 22 | ||
| Sodium gain | 22 | ||
| Clinical features | 22 | ||
| Treatment | 23 | ||
| Other osmolality disorders | 23 | ||
| 12 Hyperkalaemia | 24 | ||
| Serum potassium and potassium balance | 24 | ||
| Hyperkalaemia | 24 | ||
| Decreased excretion | 24 | ||
| Redistribution out of cells | 24 | ||
| Increased intake | 25 | ||
| Treatment | 25 | ||
| Pseudohyperkalaemia | 25 | ||
| 13 Hypokalaemia | 26 | ||
| Diagnosis | 26 | ||
| Redistribution into cells | 26 | ||
| Increased losses | 26 | ||
| Gastrointestinal | 26 | ||
| Urinary | 26 | ||
| Investigation | 27 | ||
| Treatment | 27 | ||
| 14 Intravenous fluid therapy | 28 | ||
| Does this patient need IV fluids? | 28 | ||
| Which IV fluids should be given? | 28 | ||
| How much fluid should be given? | 28 | ||
| Existing losses | 28 | ||
| Anticipated losses | 28 | ||
| How quickly should the fluids be given? | 28 | ||
| Perioperative patient | 29 | ||
| How should the fluid therapy be monitored? | 29 | ||
| 15 Investigation of renal function (1) | 30 | ||
| Functions of the kidney | 30 | ||
| Glomerular function | 30 | ||
| Serum creatinine | 30 | ||
| Estimated GFR (eGFR) | 30 | ||
| Other ways of measuring GFR | 30 | ||
| Creatinine clearance | 31 | ||
| Proteinuria | 31 | ||
| Endocrine aspects | 31 | ||
| 16 Investigation of renal function (2) | 32 | ||
| Renal tubular function | 32 | ||
| Tubular dysfunction | 32 | ||
| Investigation of tubular function | 32 | ||
| Osmolality measurements in plasma and urine | 32 | ||
| The water deprivation test | 32 | ||
| Renal tubular acidosis | 32 | ||
| Specific proteinuria | 32 | ||
| Glycosuria | 32 | ||
| Aminoaciduria | 33 | ||
| Specific tubular defects | 33 | ||
| The Fanconi syndrome | 33 | ||
| Renal stones | 33 | ||
| 17 Urinalysis | 34 | ||
| Procedure | 34 | ||
| Glucose | 34 | ||
| Bilirubin | 34 | ||
| Urobilinogen | 34 | ||
| Ketones | 35 | ||
| Specific gravity | 35 | ||
| pH (hydrogen ion concentration) | 35 | ||
| Protein | 35 | ||
| Blood | 35 | ||
| Nitrite | 35 | ||
| Leucocytes | 35 | ||
| 18 Proteinuria | 36 | ||
| Mechanisms of proteinuria | 36 | ||
| Glomerular proteinuria | 36 | ||
| Tubular proteinuria | 36 | ||
| Overflow proteinuria | 36 | ||
| Tamm–Horsfall proteinuria | 37 | ||
| Ways of measuring proteinuria | 37 | ||
| Dipstick urinalysis | 37 | ||
| Protein/creatinine ratio | 37 | ||
| Urine protein excretion | 37 | ||
| Albumin/creatinine ratio and ‘microalbuminuria’ | 37 | ||
| 19 Acute kidney injury | 38 | ||
| Aetiology | 38 | ||
| Detection of AKI | 38 | ||
| Identifying the cause of AKI | 38 | ||
| Acute tubular necrosis | 38 | ||
| Management | 39 | ||
| Recovery | 39 | ||
| 20 Chronic kidney disease | 40 | ||
| Consequences of CKD | 40 | ||
| Sodium and water metabolism | 40 | ||
| Potassium metabolism | 40 | ||
| Acid–base balance | 40 | ||
| Calcium and phosphate metabolism | 40 | ||
| Erythropoietin synthesis | 40 | ||
| Clinical features | 40 | ||
| Detection | 41 | ||
| Classification | 41 | ||
| Management | 41 | ||
| Dialysis | 41 | ||
| Renal transplant | 41 | ||
| 21 Acid–base | 42 | ||
| Hydrogen ion concentration [H+] | 42 | ||
| H+ production | 42 | ||
| Buffering | 42 | ||
| Renal handling of H+ and HCO3− | 42 | ||
| Assessing status | 42 | ||
| Acid–base disorders | 43 | ||
| Terminology | 43 | ||
| Compensation | 43 | ||
| 22 Metabolic acid–base disorders | 44 | ||
| Metabolic acidosis | 44 | ||
| The anion gap | 44 | ||
| Causes of metabolic acidosis | 44 | ||
| Clinical effects of acidosis | 45 | ||
| Metabolic alkalosis | 45 | ||
| Clinical effects of alkalosis | 45 | ||
| 23 Respiratory and mixed acid–base disorders | 46 | ||
| Respiratory acidosis | 46 | ||
| Respiratory alkalosis | 46 | ||
| Mixed acid–base disorders | 47 | ||
| 24 Acid–base disorders | 48 | ||
| Specimens for blood gas analysis | 48 | ||
| Interpreting results | 48 | ||
| Clinical cases | 48 | ||
| Management of acid–base disorders | 49 | ||
| 25 Proteins and enzymes | 50 | ||
| Enzymes | 50 | ||
| Plasma enzymes in disease | 50 | ||
| Plasma proteins | 50 | ||
| Total protein | 50 | ||
| Albumin | 50 | ||
| Specific proteins | 51 | ||
| Isoenzyme determination | 51 | ||
| Cholinesterase | 51 | ||
| 26 Immunoglobulins | 52 | ||
| Structure | 52 | ||
| Electrophoresis of serum proteins | 52 | ||
| Increased immunoglobulins | 52 | ||
| Paraproteins | 53 | ||
| Deficiencies or absence of immunoglobulins | 53 | ||
| 27 Myocardial infarction | 54 | ||
| Pathology | 54 | ||
| Cardiac biomarkers | 54 | ||
| Diagnosis | 54 | ||
| Definitions | 55 | ||
| Acute coronary syndrome | 55 | ||
| Myocardial infarction | 55 | ||
| 28 Liver function tests | 56 | ||
| Introduction | 56 | ||
| Liver function tests | 56 | ||
| The aminotransferases (ALT and AST) | 56 | ||
| Alkaline phosphatase (ALK) | 56 | ||
| Bilirubin | 56 | ||
| Gamma-glutamyl transpeptidase (GGT) | 57 | ||
| Plasma proteins | 57 | ||
| Prothrombin time | 57 | ||
| 29 Jaundice | 58 | ||
| Biochemical tests | 58 | ||
| Differential diagnosis | 59 | ||
| Haemolysis | 59 | ||
| Extrahepatic biliary obstruction | 59 | ||
| Hepatocellular damage | 59 | ||
| 30 Liver disease | 60 | ||
| Acute liver disease | 60 | ||
| Investigation | 60 | ||
| Poisoning | 60 | ||
| Liver infection | 60 | ||
| Outcome | 60 | ||
| Hepatic failure | 60 | ||
| Chronic liver disease | 60 | ||
| Aetiology | 60 | ||
| Clinical features | 60 | ||
| Unusual causes of cirrhosis | 61 | ||
| Other liver problems | 61 | ||
| 31 Glucose metabolism and diabetes mellitus | 62 | ||
| Insulin | 62 | ||
| Diabetes mellitus | 62 | ||
| Type 1 diabetes mellitus | 62 | ||
| Type 2 diabetes mellitus | 62 | ||
| Late complications of diabetes mellitus | 62 | ||
| 32 Diagnosis and monitoring of diabetes mellitus | 64 | ||
| Diagnosis of diabetes mellitus | 64 | ||
| Plasma glucose | 64 | ||
| Glycated haemoglobin (HbA1c) | 64 | ||
| Monitoring of diabetes | 64 | ||
| Self-monitoring | 64 | ||
| Ketones in urine or blood | 64 | ||
| 33 Diabetic ketoacidosis | 66 | ||
| How diabetic ketoacidosis develops | 66 | ||
| 3 Endocrinology | 79 | ||
| 40 Endocrine control | 80 | ||
| Biochemical regulators | 80 | ||
| Hormone structure | 80 | ||
| Assessment of endocrine control | 80 | ||
| Types of endocrine control | 80 | ||
| Negative feedback | 80 | ||
| Positive feedback | 81 | ||
| Pitfalls in interpretation | 81 | ||
| Dynamic function tests | 81 | ||
| 41 Dynamic function tests | 82 | ||
| Insulin stress test | 82 | ||
| TRH test | 82 | ||
| GnRH test | 83 | ||
| Oral glucose tolerance test with GH measurement | 83 | ||
| Synacthen tests | 83 | ||
| Short Synacthen test | 83 | ||
| Long Synacthen test | 83 | ||
| Dexamethasone suppression tests | 83 | ||
| Low-dose DST | 83 | ||
| High-dose DST | 83 | ||
| Dynamic function tests – protocol variation | 83 | ||
| 42 Pituitary function | 84 | ||
| The pituitary gland | 84 | ||
| Anterior pituitary hormones | 84 | ||
| Hyperprolactinaemia | 84 | ||
| Posterior pituitary hormones | 84 | ||
| Pituitary tumours | 84 | ||
| Diagnosis | 84 | ||
| Treatment | 85 | ||
| Hypopituitarism | 85 | ||
| 43 Growth disorders and acromegaly | 86 | ||
| Normal growth | 86 | ||
| Growth hormone insufficiency | 86 | ||
| Tests of growth hormone insufficiency | 86 | ||
| Treatment | 86 | ||
| Excessive growth | 86 | ||
| Acromegaly | 87 | ||
| Diagnosis | 87 | ||
| Treatment | 87 | ||
| 44 Thyroid pathophysiology | 88 | ||
| Goitre | 88 | ||
| Thyroid hormone action | 88 | ||
| Binding in plasma | 88 | ||
| Regulation of thyroid hormone secretion | 88 | ||
| Thyroid function tests | 88 | ||
| Drugs and the thyroid | 89 | ||
| 45 Hypothyroidism | 90 | ||
| Clinical features | 90 | ||
| Causes | 90 | ||
| Diagnosis | 90 | ||
| Treatment | 90 | ||
| Screening for neonatal hypothyroidism | 91 | ||
| Non-thyroidal illness | 91 | ||
| 46 Hyperthyroidism | 92 | ||
| Clinical features | 92 | ||
| Causes | 92 | ||
| Diagnosis | 92 | ||
| Treatment | 93 | ||
| Thyroid eye disease | 93 | ||
| 47 Adrenocortical pathophysiology | 94 | ||
| Cortisol | 94 | ||
| Adrenal androgens | 94 | ||
| Assessing the function of the HPA axis | 94 | ||
| Aldosterone | 94 | ||
| Congenital adrenal hyperplasia | 94 | ||
| Relationship of adrenal cortex and medulla | 95 | ||
| 48 Hypofunction of the adrenal cortex | 96 | ||
| Adrenal insufficiency | 96 | ||
| Clinical features | 96 | ||
| Pathogenesis | 96 | ||
| Diagnosis | 96 | ||
| Random cortisol | 96 | ||
| Synacthen tests | 96 | ||
| Causes of adrenal insufficiency | 97 | ||
| Relative adrenal insufficiency | 97 | ||
| 49 Hyperfunction of the adrenal cortex | 98 | ||
| Cortisol excess | 98 | ||
| Confirming the diagnosis | 98 | ||
| Overnight dexamethasone suppression test | 98 | ||
| Determining the cause | 98 | ||
| Plasma ACTH | 98 | ||
| DST | 98 | ||
| Androgen excess | 98 | ||
| Aldosterone excess | 99 | ||
| 50 Gonadal function | 100 | ||
| Sex steroid hormones | 100 | ||
| Hypothalamic–pituitary–gonadal axis | 100 | ||
| Male gonadal function | 100 | ||
| Disorders of male sex hormones | 100 | ||
| Disorders of male sexual differentiation | 100 | ||
| Female gonadal function | 100 | ||
| Disorders of female sex hormones | 100 | ||
| The androgen screen in women | 100 | ||
| 51 Subfertility | 102 | ||
| Endocrine investigations in the subfertile woman | 102 | ||
| Endocrine investigations in the subfertile man | 102 | ||
| 4 Specialised investigations | 103 | ||
| 52 Nutritional assessment | 104 | ||
| History | 104 | ||
| Examination | 104 | ||
| Biochemistry | 104 | ||
| Preoperative nutritional assessment | 105 | ||
| 53 Nutritional support | 106 | ||
| What do patients need? | 106 | ||
| Energy | 106 | ||
| Nitrogen | 107 | ||
| Fluid | 107 | ||
| Vitamins and trace elements | 107 | ||
| How should they receive nutrition? | 107 | ||
| Monitoring patients | 107 | ||
| 54 Parenteral nutrition | 108 | ||
| Indications for parenteral nutrition | 108 | ||
| Route of administration | 108 | ||
| Components of TPN | 108 | ||
| Complications | 108 | ||
| Monitoring patients on TPN | 109 | ||
| 55 The metabolic response to injury | 110 | ||
| The phases of the metabolic response to injury | 110 | ||
| The acute phase protein response | 110 | ||
| Clinical uses | 111 | ||
| Starvation and the metabolic response to injury | 111 | ||
| 56 Gastrointestinal disorders | 112 | ||
| Physiology of digestion and absorption | 112 | ||
| Malabsorption | 112 | ||
| Gastrointestinal disorders | 112 | ||
| Gastro-oesophageal | 112 | ||
| Pancreas | 113 | ||
| Small intestine | 113 | ||
| Inflammatory bowel disease | 113 | ||
| Malignant disease | 113 | ||
| 57 Iron | 114 | ||
| Iron physiology | 114 | ||
| Laboratory investigation of iron disorders | 114 | ||
| Iron deficiency | 114 | ||
| Treatment | 114 | ||
| Iron overload | 115 | ||
| Haemochromatosis | 115 | ||
| Iron poisoning | 115 | ||
| 58 Zinc and copper | 116 | ||
| Zinc | 116 | ||
| Zinc physiology | 116 | ||
| Zinc deficiency | 116 | ||
| Zinc toxicity | 116 | ||
| Laboratory assessment | 116 | ||
| Copper | 116 | ||
| Copper physiology | 116 | ||
| Copper deficiency | 116 | ||
| Copper toxicity | 116 | ||
| Laboratory assessment | 117 | ||
| Inborn errors of copper metabolism | 117 | ||
| Wilson’s disease | 117 | ||
| 59 Therapeutic drug monitoring | 118 | ||
| Sampling for TDM | 118 | ||
| Interpretation of drug levels | 118 | ||
| Drug interactions | 119 | ||
| Pharmacokinetics | 119 | ||
| 60 Toxicology | 120 | ||
| Confirming poisoning | 120 | ||
| Measurement of drug levels | 120 | ||
| Treatment | 120 | ||
| Common causes of poisoning | 120 | ||
| Chronic poisoning | 121 | ||
| 61 Metal poisoning | 122 | ||
| Metals associated with poisoning | 122 | ||
| Diagnosis | 122 | ||
| Treatment | 122 | ||
| Common sources | 122 | ||
| Lead | 122 | ||
| Mercury | 123 | ||
| Aluminium | 123 | ||
| Arsenic | 123 | ||
| Cadmium | 123 | ||
| Cobalt and chromium | 123 | ||
| 62 Alcohol | 124 | ||
| Metabolism of ethanol | 124 | ||
| Acute alcohol poisoning | 124 | ||
| Chronic alcohol abuse | 124 | ||
| Diagnosis of chronic alcohol abuse | 125 | ||
| 63 Ascites | 126 | ||
| Peritonitis | 126 | ||
| Early detection | 126 | ||
| SBP or secondary infection | 126 | ||
| Microbiology | 126 | ||
| Malignant ascites | 127 | ||
| Malignant or benign | 127 | ||
| Other | 127 | ||
| Sample requirements | 127 | ||
| 64 Pleural fluid | 128 | ||
| Transudate or exudate? | 128 | ||
| Is it empyema? | 128 | ||
| Is it malignant? | 129 | ||
| Is it chyle? | 129 | ||
| Is it tuberculosis? | 129 | ||
| 65 Cerebrospinal fluid | 130 | ||
| Lumbar puncture | 130 | ||
| Subarachnoid haemorrhage | 130 | ||
| Xanthochromia | 130 | ||
| Meningitis | 130 | ||
| Inherited metabolic disorders | 130 | ||
| Other conditions | 131 | ||
| Dementia | 131 | ||
| 66 Identification of body fluids | 132 | ||
| Cerebrospinal fluid | 132 | ||
| Lymph and chyle | 132 | ||
| Urine | 133 | ||
| Other | 133 | ||
| Amniotic fluid | 133 | ||
| Synovial fluid | 133 | ||
| 67 Lipoprotein metabolism | 134 | ||
| Nomenclature | 134 | ||
| Metabolism | 134 | ||
| The exogenous lipid cycle | 134 | ||
| The endogenous lipid cycle | 134 | ||
| Apolipoproteins | 134 | ||
| The LDL receptor | 134 | ||
| 68 Clinical disorders of lipid metabolism | 136 | ||
| Classification | 136 | ||
| Primary | 136 | ||
| Secondary | 136 | ||
| Atherogenic profiles | 136 | ||
| 69 Hypertension | 138 | ||
| Causes of hypertension | 138 | ||
| Treatment of hypertension | 139 | ||
| 70 Cancer and its consequences | 140 | ||
| Local effects of tumours | 140 | ||
| Cancer cachexia | 140 | ||
| Paraneoplastic syndromes and ectopic hormone production | 141 | ||
| Consequences of cancer treatment | 141 | ||
| 71 Tumour markers | 142 | ||
| The use of tumour markers | 142 | ||
| Monitoring treatment | 142 | ||
| Assessing follow-up | 142 | ||
| Diagnosis | 142 | ||
| Prognosis | 142 | ||
| Screening for the presence of disease | 142 | ||
| A practical application of tumour markers | 142 | ||
| Tumour markers with established clinical value | 143 | ||
| The future | 143 | ||
| 72 Multiple endocrine neoplasia | 144 | ||
| MEN 1 | 144 | ||
| MEN 2 | 144 | ||
| MEN 2A | 144 | ||
| MEN 2B | 144 | ||
| Familial medullary carcinoma of the thyroid | 144 | ||
| Screening and treatment | 144 | ||
| The APUD concept | 144 | ||
| Carcinoid tumours | 145 | ||
| Insulinomas | 145 | ||
| Others | 145 | ||
| 73 Hyperuricaemia | 146 | ||
| Urate formation and excretion | 146 | ||
| Lesch–Nyhan syndrome | 146 | ||
| Gout | 146 | ||
| Treatment | 146 | ||
| Renal disease and hyperuricaemia | 146 | ||
| Urate in pregnancy | 146 | ||
| 74 Myopathy | 148 | ||
| Muscle weakness | 148 | ||
| Investigation | 148 | ||
| Rhabdomyolysis | 148 | ||
| Investigation and treatment | 149 | ||
| Duchenne muscular dystrophy | 149 | ||
| 75 Fetal monitoring and prenatal diagnosis | 150 | ||
| HCG | 150 | ||
| Fetoplacental function | 150 | ||
| Prenatal diagnosis | 150 | ||
| Alpha-fetoprotein | 150 | ||
| Bilirubin | 151 | ||
| Fetal blood gases | 151 | ||
| 76 Pregnancy | 152 | ||
| Maternal physiology | 152 | ||
| Weight gain | 152 | ||
| Respiratory function | 152 | ||
| Renal function | 152 | ||
| Carbohydrate metabolism | 152 | ||
| Protein metabolism | 152 | ||
| Hormonal changes | 152 | ||
| Pregnancy-associated pathology | 152 | ||
| Gestational diabetes | 152 | ||
| Hypertension | 153 | ||
| Obstetric cholestasis | 153 | ||
| Drugs in pregnancy | 153 | ||
| 77 Antenatal screening | 154 | ||
| Overview of screening programmes | 154 | ||
| Screening for Down syndrome | 154 | ||
| First-trimester screening | 154 | ||
| Nuchal translucency | 154 | ||
| Biochemical tests | 154 | ||
| Risk calculation | 154 | ||
| 5 Case history comments | 163 | ||
| 82 Case history comments | 164 | ||
| Case history 1 | 164 | ||
| Case history 2 | 164 | ||
| Case history 3 | 164 | ||
| Case history 4 | 164 | ||
| Case history 5 | 164 | ||
| Case history 6 | 164 | ||
| Case history 7 | 164 | ||
| Case history 8 | 164 | ||
| Case history 9 | 165 | ||
| Case history 10 | 165 | ||
| Case history 11 | 165 | ||
| Case history 12 | 165 | ||
| Case history 13 | 165 | ||
| Case history 14 | 165 | ||
| Case history 15 | 165 | ||
| Case history 16 | 165 | ||
| Case history 17 | 166 | ||
| Case history 18 | 166 | ||
| Case history 19 | 166 | ||
| Case history 20 | 166 | ||
| Case history 21 | 166 | ||
| Case history 22 | 166 | ||
| Case history 23 | 166 | ||
| Case history 24 | 166 | ||
| Case history 25 | 166 | ||
| Case history 26 | 166 | ||
| Case history 27 | 167 | ||
| Case history 28 | 167 | ||
| Case history 29 | 167 | ||
| Case history 30 | 167 | ||
| Case history 31 | 167 | ||
| Case history 32 | 167 | ||
| Case history 33 | 167 | ||
| Case history 34 | 167 | ||
| Case history 35 | 167 | ||
| Case history 36 | 168 | ||
| Case history 37 | 168 | ||
| Case history 38 | 168 | ||
| Case history 39 | 168 | ||
| Case history 40 | 168 | ||
| Case history 41 | 168 | ||
| Case history 42 | 168 | ||
| Case history 43 | 168 | ||
| Case history 44 | 169 | ||
| Case history 45 | 169 | ||
| Case history 46 | 169 | ||
| Case history 47 | 169 | ||
| Case history 48 | 169 | ||
| Case history 49 | 169 | ||
| Case history 50 | 169 | ||
| Case history 51 | 169 | ||
| Case history 52 | 169 | ||
| Case history 53 | 170 | ||
| Case history 54 | 170 | ||
| Case history 55 | 170 | ||
| Case history 56 | 170 | ||
| Case history 57 | 170 | ||
| Case history 58 | 170 | ||
| Case history 59 | 170 | ||
| Case history 60 | 170 | ||
| Index | 171 | ||
| A | 171 | ||
| B | 172 | ||
| C | 172 | ||
| D | 173 | ||
| E | 173 | ||
| F | 173 | ||
| G | 174 | ||
| H | 174 | ||
| I | 175 | ||
| J | 175 | ||
| K | 175 | ||
| L | 175 | ||
| M | 176 | ||
| N | 176 | ||
| O | 177 | ||
| P | 177 | ||
| Q | 177 | ||
| R | 178 | ||
| S | 178 | ||
| T | 178 | ||
| U | 179 | ||
| V | 179 | ||
| W | 179 | ||
| X | 179 | ||
| Z | 179 | ||
| Inside Back Cover | ibc1 |