2nd June [7-13th] Flashcards
Normal range of creatinine for men
97-157 umol/l
Normal range of creatinine for women
88-128 umol/l
Which drug may cause red urine on a haematology ward?
Dionirubicin
Symptoms of haemorrhoids
Bright red blood after wiping, anal pruritus, lumps, pain
What are the three signs that predict if smouldering myeloma will progress into MM
with 80% chance:
- FLC ratio of over 100
- Plasmocytosis 60%
- CS imaging [e.g. MRI] to show lytic lesions
Common drugs that cause postural hypotension
Diuretics, alpha-adrenoecptor blockers for prostatic hypertrophy, antihypertensive drugs, CCB.
Insulin, levodopa, tricyclic antidepressants can also cause vasodilation and orthostatic hypotension in predisposed patients.
What is tazocin?
piperacillin with tazobactam
When can it be used?
For management of neutropenic patients with fever suspected to be due to bacterial infection
What is an autologous blood transfusion?
Collection and re-infusion of patient’s own blood or blood components
What is GvHD?
Graft versus host disease
- when transplantation occurs and there’s a bodily reaction to the new blood/tissue as immune system thinks it is foreign
- often it’s very mild, but can affect QoL in certain cases
- can be life threatening
How common is GvHD?
About half people who have a transplant get it
Type sof GvHD
- Acute: happens first 100 days after transplant
- Chronic: happens after 100 days post-transplant
- Progressive: when acute GvHD progresses to chronic GvHD
- Overlap: when features of acute and chronic GvHD happen together
When are you likely to get GvHD?
When am I likely to get GvHD?
GvHD can occur at any time, so it’s important to report any symptoms after transplant to your team. However, the most common times to experience GvHD are:
When your immune cells start to come back and appear in your blood, usually a few weeks after your transplant.
When the medication that suppresses your immune system is reduced, usually a few months after you go home. The immune cells become more active, notice there’s a difference in your body’s cells and may start an attack.
If you have a donor lymphocyte infusion (DLI) – this is a top-up of donor cells which can sometimes be given if your new immune system needs a boost.
Ix for GvHD
Some symptoms are quite general and don’t always mean you have GvHD. Your medical team will perform tests that might include biopsies (skin or liver GvHD) or use a small camera to look closely at the organ (stomach or lung GvHD). These tests can confirm the GvHD diagnosis.
Tx for GvHD
What are the treatments for GvHD?
Treatment for GvHD varies depending on the organ involved. It can be broken down into:
Local - This includes creams for skin GvHD, drops for eye GvHD and physiotherapy for GvHD of the joints.
Oral - Immunosuppressive medication (cyclosporine, mycophenolate or tacrolimus) will be given before your transplant to suppress your immune system and allow new stem cells to grow. If you develop GvHD, the dose might need to be increased for a while to control your symptoms. Oral steroids may also be used for immunosuppression. Once the GvHD has improved, these medications will slowly be reduced again.
Intravenous - Might be used if oral medications don’t control the GvHD. This might require an admission into hospital for treatment.
In some cases, acute or chronic GvHD cannot be controlled with these medications so further treatment, such as extracorporeal photopheresis (ECP) or referral to a specialist might be needed.
GvHD in the skin, gut, mouth and liver
Skin
Symptoms: Acute and chronic skin GvHD symptoms are very similar. Your skin is likely to become dry, red and itchy and it could affect multiple areas of your body. This can affect your appearance, ability to regulate your temperature and lead to infection if the skin is broken.
Treatment: Some cases need no treatment and improve naturally. Mild cases are treated using moisturises or steroid cream. Medication to supress your immune system in more severe cases and treatments such as ultraviolet light and extracorporeal photopheresis (ECP) are possible options.
Gut
Symptoms: Gut GvHD could affect your mouth, oesophagus (food pipe), stomach and bowel. Acute gut GvHD usually affects the bowel. You could have sickness, diarrhoea, indigestion, cramping feelings and lack of appetite.
Treatment: Mild cases don’t need treatment but dehydration should be avoided by drinking lots of fluids. More severe cases might need anti-diarrhoea medication, painkillers to ease cramps and anti-sickness drugs to stop you feeling sick.
Mouth
Symptoms: Your mouth may become sore and dry because you aren’t producing enough saliva. This may lead to ulcers forming and can make your food taste unusual.
Treatment: Visit your dentist regularly if you have mouth GvHD. Practising good oral hygiene and using a steroid mouthwash may also help.
Liver
Symptoms: To begin with you might not feel anything but your doctor might find out that something is wrong by testing your liver function. If it becomes worse you may become jaundiced, (yellowing of skin) and your skin may itch. Your liver may also swell in size, causing abdominal pain.
Treatment: Steroids and other drugs to suppress your immune system.
GvHD in the lungs, eyes, muscles and joints, genitals
Lung
Symptoms: Your lungs can lose some of their flexibility and elasticity, making you feel short of breath, wheezy and prone to coughs and chest infections. You might find exercising becomes more difficult. If you experience any of these symptoms you should contact your medical team straight away.
Treatment: Tests such as lung function, chest X-rays, CT scans and sometimes bronchoscopies (a type of endoscopy that looks inside your airways) to find out what’s causing your problems and rule out infection.
Eyes
Symptoms: Your eyes may become itchy, dry and uncomfortable or they may water almost continuously. They may also be sensitive to bright light.
Treatment: Referral to an ophthalmology specialist that can prescribe a combination of eye drops, anti-inflammatories or antibiotics depending on your symptoms. Wearing sunglasses may also helpful.
Muscles & joints
Symptoms: Restricted movement and pain in the joints of your arms and legs, making tasks such as driving or climbing stairs more difficult. Some patients experience swollen joints.
Treatment: Physiotherapy can improve your symptoms and will involve doing lots of stretches and keeping your joints mobile.
Genitals
Symptoms: Women may experience vaginal dryness, narrowing of the vagina and ulceration in advanced cases - causing pain and discomfort during sex.
Men may experience sensitivity or a rash on their penis and it could be uncomfortable to pass urine. They may also experience problems maintaining an erection.
Treatment: Women will be referred to a gynaecologist that may prescribe a steroid cream or gel to combat dryness. Men will be referred to a urologist and may also be prescribed a steroid cream to reduce sensitivity.
What is ECP?
ECP is a treatment used for acute and chronic skin, liver and oral GvHD. It aims to destroy the white blood cells that cause GvHD by combining a medication called methoxypsoralen (8-MOP) with ultraviolet (UV) light.
The procedure involves being attached to a machine that removes your blood through a cannula and drip. It then separates the white cells from your blood, before returning the blood to your body. The white cells are then exposed to UV light and 8-MOP to destroy the cells that cause GvHD, and then returned to your body.
Treatment can take 1–2 hours. You might start by having two appointments per week, every fortnight. Over time (depending on your response) treatment cycles are likely to reduce. ECP for acute GvHD responds quite quickly, whereas ECP for chronic GvHD can take six months or more before any improvement. In some cases, treatment can last 12–18 months or longer.
Referral for ECP can seem daunting, due to the length of treatment. Sometimes patients delay it as long as possible – but the timing of ECP is crucial for it to be most effective. It’s essential that if your doctor suggests a referral for ECP you consider it carefully. Leaving it too long could reduce the effectiveness of the treatment.
Top tips for managing GvHD
Report any changes in your GvHD to your transplant team immediately. GvHD can worsen quickly if not treated appropriately. Call your CNS or a member of the team who can offer advice and in most cases prevent the need to come into clinic.
Take your immunosuppression medication as advised. This is one of the most important medications you’ll need to take.
GvHD and its treatment can have knock-on effects so you might be referred to other healthcare professionals such as a dietician or physio. It’s important that you follow their advice to prevent weight loss, manage fatigue and maintain fitness.
Treatment for GvHD can put you more at risk of infection, so report any change in your temperature to your transplant team immediately.
Cyclosporin SE
Gingival hyperplasia, excess hair growth
What is TBI?
Total body irradiation:
- form of radiotherapy used primarily as part of the preparative regimen for haematopoietic stem cell [or bone marrow] transplantation
- Total body irradiation in the setting of bone marrow transplantation serves to destroy or suppress the recipient’s immune system, preventing immunologic rejection of transplanted donor bone marrow or blood stem cells. Additionally, high doses of total body irradiation can eradicate residual cancer cells in the transplant recipient, increasing the likelihood that the transplant will be successful
Which part of the body is shielded commonly in TBI and why?
Lungs usually shielded to lower the risk of radiation-induced lung injury
What is the diameter of the spleen?
Usually about 12cm
Upper limit around 14cm in taller males
What is the only way to differentiate between central-peripheral consumption of platelets?
BMB
Causes of splenomegaly
infection - viral such as mononucleosis - parasitic infection like toxoplasmosis - bacterial like endocarditis Ca - leukemia - lymphoma Other - inflammation like sarcoidosis/RA - trauma - Ca mets - cysts - abscess - infiltrate like amyloidosis
Sx of splenomegaly
Unable to eat large meal
Pain ULQ or left shoulder
Monitoring patients with MGUS
CRAB features
Any other CF of note etc.
I think yearly bloods?
When is acyclovir used in haematology?
Prevention of cytomegalovirus infections following transplant
What is plasma cell leukemia?
rare type of cancer characterised by unusually high levels of plasma cells in the blood
Similar to myeloma, PCL affects plasma cells normally found in bone marrow.
2-4% of all plasma cell melaginancies
Anatomical position of the spleen
Located ULQ of the abdomen, under cover of the diaphragm and the ribcage - therefore cannot be normally palpated on clinical examination [except when enlarged].
Retroperitoneal organ, surrounded entirely by peritoneum.
How is the spleen connected to the stomach/kidney?
The spleen is connected to the stomach and kidney by parts of the greater omentum – a double fold of peritoneum that originates from the stomach:
Gastrosplenic ligament – anterior to the splenic hilum, connects the spleen to the greater curvature of the stomach.
Splenorenal ligament – posterior to the splenic hilum, connects the hilum of the spleen to the left kidney. The splenic vessels and tail of the pancreas lie within this ligament
What is between the gastrosplenic and splenorenal ligaments?
The lesser sac
Shape fo the spleen
The spleen has a slightly oval shape. It is covered by a weak capsule that protects the organ whilst allowing it to expand in size
Surface of the spleen
The outer surface of the spleen can be anatomically divided into two:
Diaphragmatic surface – in contact with diaphragm and ribcage.
Visceral surface – in contact with the other abdominal viscera.
It has anterior, superior, posteromedial and inferior borders. The posteromedial and inferior borders are smooth, whilst the anterior and superior borders contain notches.
What can be palpated in splenomegaly?
In enlargement of the spleen (known as splenomegaly), the superior border moves inferomedially, and its notches can be palpated.
Vasculature of the spleen?
The spleen is a highly vascular organ. It receives most of its arterial supply from the splenic artery. This vessel arises from the coeliac trunk, running laterally along the superior aspect of the pancreas, within the splenorenal ligament. As the artery reaches the spleen, it branches into five vessels – each supplying a different part of the organ.
These arterial branches do not anastomose with each other – giving rise to vascular segments of the spleen. This enables a surgeon to remove one of these segments without affecting the others (a procedure known as a subtotal splenectomy).
Venous drainage occurs through the splenic vein. It combines with the superior mesenteric vein to form the hepatic portal vein.
What is a rupture of the spleen?
The spleen is the abdominal organ with the highest incidence of injury. A splenic rupture occurs when there is a break in its fibroelastic capsule, disrupting the underlying parenchyma.
Often the cause of splenomegaly?
Rupture is caused by blunt or penetrating trauma. It is often associated with left rib fractures, with a bony fragment easily tearing the capsule
When is a splenectomy considered?
As the spleen is a highly vascular organ, its rupture results in profuse bleeding into the peritoneal cavity. Splenectomy is indicated where injury to the spleen and subsequent haemorrhage are life threatening. This may be done as a sub-total (partial) splenectomy – recall that there are no arterial anastomoses in the spleen – or as a total splenectomy.
Further indications for splenectomy include haematological conditions such as haemolytic anaemia, idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, hypersplenism and prolieferative disorders such as myelofibrosis of lymphoma.
What takes over some of the functions of the spleen if there is spleen damage?
The liver and bone marrow take over some of the functions of the spleen, however, an individual who has no spleen is more susceptible to some bacterial infections and as such, requires life long antibiotics.
Causes of microcytic anaemia
5 main causes [TAILS]
- Thalasemmia
- Anaemia of chronic disease
- IDA
- Lead poisoning
- Congenital sideroblastic anaemia
What is the normal erythrocyte volume?
About 80-100 femolitres
Causes of macrocytic anaemia
Megaloblastic anaemias
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