Haem, Onc, Palliative Care Flashcards
What causes a normocytic anaemia?
Anaemia without altered RBC structure
Anaemia of chronic disease
Acute blood loss
Aplastic anaemia
Haemolytic anaemia
What are the causes of microcytic anaemia
Thalassaemia: AR defects of haem chains
Anaemic of chronic disease
Iron deficency:can also be normocytic
Lead poisoning: blocks heme synthesising enzymes
Sideroblastic: Iron wont fit into RBCs
How do you investigate iron deficiency anaemia?
FBCs showing low Hb, can confirm if low ferritin
What is the initial management of iron deficiency anaemia?
- oral iron
+ IV iron or blood transfusion
For anaemia, when do you refer to…
Haematology
Supplementation fails to increase by 20g/L over 2-4 weeks and no GI or Gynae criteria
Paraesthesia, changes to mood and vision+/- mild jaundice suggests which anaemia?
B12 deficiency
What investigations suggest B12 deficiency
Macrocytic anaemia
Hypersegmented polymorphs
Low cobalamin is B12, low folate is folate
How do you treat B12 deficiency?
No neuro: IM hydroxycobalamin 3x day 2 weeks; 1 per 3 months afterwards
Neuro: IM 1mg every other day until improves
TREAT B12 BEFORE FOLATE
give folic acid 5mg day 4 months
When do you refer a vit B12 deficiency to…
Haem
Gastro
Haem: Uncertain, malignancy, resistant to treatment
Gastro: IBD, malabsorption, GI malignancy
How doe sickle cell present on…
FBC
Blood film
Microcytic anaemia
Sickle cells, howell-Jolly bodies
Outline the inheritance of sickle cell anaemia
AR inheritance of HbS instead of A.
One gene casues trait
Two causes disease
Compare vaso-occlusive, splenic sequestration, aplastic crisis and acute chest syndrome in terms of…
Pain
Associated symptoms
Lab findings
VOC // SS // AC // ACS
Localised pain // abdo pain // painless // painless
Fever, priapism // HSM, hypotension // infective Hx // Resp symptoms
Raised Hc // Severe anaemia // severe anaemia // Infiltrates on X-ray
How do you treat sickle cell crises?
Admit
Treat infection
IV fluids
Keep warm
Analgesia
Aspirate if priapism
What prophylaxis is given to sickle cell patients
Penicillin 3m-5yrs
PPV23 every 5 years
MenB + ACWY then another MenB 4 weeks later
What patient features might point towards thalassaemia?
Pronounced forehead and jaw
Jaundice, gallstone, splenomegaly
How do you diagnose thalassaemia?
Haem electrophoresis
DNA testing
How do you treat thalassaemia that is
alpha
Beta…
minor
intermedia
major
Alpha: monitor. Transfusions and bone marrow transplant potentially.
Bm: Conservative
BI: monitor + transfuse
BM: regular transfusion, chelation and splenectomy. Bone transplant can be curative
Anaemia + gallstones + large spleen
Blood film…
Diagnose and treat
Hereditary spherocytosis
Folate supplementation + splenectomy
Patient with PMHx of infections + jaundice after eating beans
G6PD deficiency
Heinz enzyme assay to confirm
Avoid triggers
What are the features of leukaemia?
Abnormal bruising
Splenomegaly, lymphadenopathy
Palness, fever, fatigue
Where suspected, what are the 1st line and GS test in leukaemia?
1st: <48hr FBC
GS: Bone marrow biopsy
+ blood film biopsy
How are the leukaemias distributed by age?
ALL CLLmates have CMMon AMbitions
ALL: <5s, >45s
CLL: Over 55
CML: Over 65
AML: Over 75
How can ALL, CLL, AML and CML be differentiate based on
Clinical history
Blood results
ALL: Children, Down’s syndrome, Blast cells (left)
CLL: Most common in adults, Smudge cells (right
AML: Myeloproliferative, Auer rods (middle)
CML: Raised WCC/low Hb, plts, pancyto
How do you treat leukaemia?
Chemo and steroids
What are the general features of a lymphoma?
Painless, assymetrical lymphadenopathy
+ systemic B symptoms
How do NHL and HL differ on…
Age
Symptoms
Cells
Associations
NHL // HL
>75s // 20s, 70s
Early B symptoms, extra-nodal disease // painful nodes on alcohol
Depends on subtype // Reed sternberg cells
How is Lymphoma confirmed?
Lymph node biopsy
+CT/MRI/PET
What is myeloma and its subgroups
Plasma cell malignancy resulting in excess antibody production
MGUS: Raised antibodies without specific infection
Multiple myeloma: affected multiple sites
Smouldering: MGUS progression with higher Ig levels; waldenstrom’s if specifically IgM raised
>60s presents with bone pain.
Bloods show rasied calcium, total protein and renal impairment
What is the diagnosis
myeloma
What investigations are performed in suspected myeloma?
Monoclonal IgM or IgA in serum and urine (BJ proteins)
Increased plasma cells on bone marrow biopsy
Whole body MRI for bone lesions
+ ‘tear-drop skull’ on X-ray
B symptoms + splenomegaly + the following bloods indicate what?
Raised Hb
Raised platelets
Low Hb, abnormal platelets + WCC, teardrop RBCs
Myeloproliferative disorders
Polycythaemia vera
Essential thrombocytopaenia
Myelofibrosis
How do you treat…
Polycythaemia vera
Essential thrombocytopaenia
MF
PC: Venesection, chemo
ET: chemo
MF: Chemo + stem cell transplant
How do you stage Hodgkin’s lymphoma?
Ann-Arbor staging
I: Single lymph node
II: 2 or more nodes/regions on same diaphragm side
III: Nodes on both sides of diaphragm
IV: Spread beyond lymph nodes
+ A: Pruritis only
B: >10% weight loss, fever >38 degrees, night sweats
What are the diagnostic criteria for myeloma
Factor: Major // minor
Imaging: Plasmacytoma // osteolytic lesions
Plasma cells: 30% // 10-30%
M protein: Elevated // minor elevations
+ low antibody levels for minor
NEED 1 MAJOR + 1 MINOR / 3 MINOR
What are the subtypes of non-hodgkin’s lymphoma and their associations?
Burkitt’s: EBV, tumour lysis, ‘starry sky’ histology
MALT: H. pylori, perigastric tissue
Diffuse B cell: rapidly growing painless mass in >65yrs
Muscle cramps in a NHL patient just starting chemo suggests what and how is it prevented?
Tumour lysis syndrome in burkitt’s lymphoma
Give rasburicase to prevent uric acid –> allantoin
Allopurinol is alternative
Infant experiencing painful swelling in hands and feet in absence of other pathology suggests what?
Thrombotic crises
How can you distinguish ITP, TTP and DIC in terms of…
Symptoms
Labs
Cells
ITP // TTP // DIC
Bleeding // ‘The Terrible Pentad’* // Bleeding, sepsis
high bleed time // high bleed, low platelets // high bleed, low platelets + D-dimer
none // schistocytes // schistocytes
Polycythaemia rubra vera is most likely to convert into which cancer?
AML or myelofibrosis
What test confirms the diagnosis if spherocytes are found on blood film?
DIRECT coomb’s test
confirms diagnosis of haemolytic anaemia
What is offered for palliative pain intially?
Unless co-morbidities…
20-30mg MR morphine daily + 5mg breakthrough pain
+ Laxatives
Nausea and drowsiness should be transient
What should be offered as therapy for those with renal impairment?
Mild-mod: Oxycodone
Severe: Buprenorphine, fentanyl, alfentanil
What pain relief is available for bone pain?
Strong opioids
Bisphosphonates
Radiotherapy
How much should you increase an opioid dose?
30-50%
How do you convert between
oral codeine and morphine
Oral tramadol and oral morphine
Divide both instances by 10
How do you convert…
Oral morphine to SC morphine
Oral morphine to SC diamorphine
Oral oxycodone to SC diamorphine
/2
/3
/1.5
How much oral morphine are the following equal to…
TD fentanyl 12ug
TD buprenorphine 10mg
30mg
24mg
If a palliative patient is agitated or confused what do you give
1st line
Alternatives
If in terminal phase
Haloperidol
-promazines
midazolam
Antiemesis for GI related stasis
Metoclopramide (unless prokinesis will worsen eg obstruction)
Domperidone
Antiemesis for chemical nausea (eg chemo)
Correct the cause first
Ondansetron/haloperidol/levomepromazine
Antiemesis for visceral/serosal causes of nausea
Cyclizine, levopromazine
+ Anti-cholinerigcs eg hyoscine
Antiemesis for raised intracranial pressure
Cyclizine for nausea
Dexamethasone can be used
Radiotherapy to reduce mass effect
Antiemesis for vestibular nausea
Cyclizine
Metoclopramide/prochlorperazine if refractory
Antiemesis for anxiety/pain (cortical)
Antiemesis for anxiety/pain (cortical)
For syringe drivers what is…
Used for respiratory secretions
the choice for pain
the drug that can cause interactions most generally
Hyoscine, glycopyrronium
Diamorphine
Cyclizine
What is good for mouth pain in palliative care
Generally
With evidence of gum disease
Benzydamine hydrochloride
What can you give for hiccups in palliative care
Chlorpromazine or haloperidol
What are the top 5 cancers in terms of:
Prevalence
Mortality
Prevalence // Mortality
1. Breast // Lung
2. Lung // Colorecal
3. Colorectal // Breast
4. Prostate // Prostate
5. Bladder // Pancreas
What biomarker indicates poor prognosis in myeloma
Raised B2 microglobulin
How can you differentiate G6PD and hereditary spherocytosis
G6PD // Hereditary spherocystosis
Both: Neonatal jaundice + gallstones
Haemolysis: Drugs/infection // chronic
Inheritance: X-linked // AD
Splenomegaly: Less common // more common
Blood film: Heinz bodies // spherocytes
Diagnostic test: G6PD enzyme activity // EMA binding
How is the does the BCR-ABL protein…
Come about
Affect cell activity
Translocation of philadelphia chromosome (9:22)(Q34;Q11)
Creates abnormally active tyrosine kinase
Subsequent phosphorylation leads to continuous cell division and proliferation.results
What cancer are the following markers linked to
CA15-3
CA19-9
CA125
CEA
AFP
Breast
Pancreatic
Ovarian
Colorectal
Hepatocellular
What is the universal donor of FFP
AB (does not contain antibodies)
What primary immunodeficiencies are neutrophil disorders
Chronic granulomatous disease: NADPH oxidase reduces phagocytic ROS
Chediak-Higashi: microtubule defect reduces phagocytosis
Leukocyte adhesion deficiency
What drugs can induce symptoms in G6PD
Anti-malarials
Cipro
Sulph-group drugs
Which neutrophil disorder are the following
Recurrent pneumonia due to catalase +ve bacteria
Partial albinism + bacterial infections + giant granules in neutrophils
Recurrent infections + delayed umbilical cord sloughing + absence of neutrophils at infection sites
Chronic granulomatous disease
Chediak Highashi syndrome
Leukocyte adhesion deficiency
What are the primary B cell disoders
Common variable ID: low IgA/G/M
Bruton’s congenital agammaglobulinaemia: X-linked recessive + absent B cells + reduced IgG
Selective immunoglobulin A ID: Severe reactions to blood transfusions + positive coeliac testing
What T cell disorder causes primary immunodeficiency?
DiGeorge: Cleft palate + Tetralogy of Fallot + learning needs
What are the combined B+T cell primary immunodeficiencies
SCID WAS Ataxic
SCID: Reduced T cell receptor excision
Wiskott-Aldrich: X-linked recessive + eczema + low IgM
Ataxic telangectasia: Autosomal recessive
What blood film result can be seen in lead poisoning
Basophilic stippling
What are the following translocations associated with
9;22
15;17
8;14
11;14
14;18
9;22: CML, poor prognosis in AML
15;17: APML
8;14: Burkitt’s lymphoma (Burkitt has 8 letters)
11;14: Mantle cell lymphoma
14;18: follicular lymphoma (18 as most letters)
What is the key investigation in chronic lymphocytic leukaemia?
Immunophenotyping
Which haemolytic anaemias are
Intravascular
Extravascular
Intra: MRCGP
Mismatched transfusion
Red cell fragmentation: DIC, HUS, TTP
Cold AIHA
G6PD deficiency
Paroxysmal nocturnal haemoglobinuria
Extra: 4 Hs
HDNB
Hereditary spherocytosis
Haemoglobinopathies
Hot (warm) AIHA
What is the most common organisms (by lab grouping) in neutropaenic sepsis?
Gram positive, coag negative bacteria
What cancer is BRCA2 associated with in men
Prostate
Which chemotherapies cause
Haemorrhagic cystitis
Lung fibrosis
Cardiomyopathy
Lung + liver fibrosis
Dermatitis
Ataxia
Periperhal neuropathy + paralytic ileus
Nerve damage + low magnesium
Cyclophosphamide
Bleomycin
Antracyclines (doxorubicin)
Methotrexate
5-FU
Cytarabine (cytara-been drinking too much = ataxia)
Vincristine/vinblastine
Cisplatin
Which chemotherapies DO NOT cause myelosuppression
Bleomycin
Anthracyclines
Docetaxel
Cisplatin
What is the first line treatment for ITP
Oral prednisolone
What is the most common inherited
Bleeding disorder
Thrombophilia
Von Willebrand’s (Reduced platelet activity + factor VIII)
Factor V leiden (activated protein C resistance)
What are contraindications to platelet transfusions?
Chronic bone marrow failure
Thrombocytopaenias: Heparin, Autoimmune, TTP
What is the threshold for platelet transfusion
Stable
Unwell
Pre-op
10
30
50
Outline the ECOG score
0: Independent
1: Restricted to light work
2: Ambulatory but unable to work; >50% up and about
3: Limited selfcare, <50% up and about
4: Completely disabled, bedbound
5: Dead
What haem condition sees angioedema without urticaria +/- preceding macular rash
What serial blood markers are useful
How do you treat
Hereditary angioedema
C1-INH, C2-4 low
C1 inhibitor concentrate/FFP
What are the risk factors of cervical cancer
HPV
Huffing cigs
HIV
What condition is a result of failure to cleave vWF normally
TTP
What is a leukaemoid reaction and how is it differentiated from CML
Presence of immature cells in peripheral blood due to increased strain on bone marrow production (haemolysis, haemorrhage, cancer)
Leukaemoid // CML
l-ALP: High // low
toxic granulation of WCC // none
left shift (<3 segments) // no left shift of neutrophils
What is the rarest thrombophilia?
Antithrombin III deficiency (highest VTE risk though)
How can you quickly determine from lab values which bleeding disorder you have?
Haemophilia (1 word): APTT
vWB: APTT, PT
DIC (3 words): APTT, PT, BT
How can vWB, haemophilia, antiphospholipid syndrome be differentiated since it causes prolonged APTT
vWB // haemophilia
// low factor XIII (A) or IX (B)
Why are anaphylaxis patients observed for a day?
Biphasic reactions 20% patients
What blood test findings indicate thalassaemia
How can alpha and B be distinguished
Disproportionate microcytic anaemia
Electrophoresis: Normal in A, HBA2 raised in B
Raised K, PO4, Uric acid + low Ca indicates what post chemo?
When is it deemed clinically worrying?
How is it managed?
Tumour lysis syndrome
Clinical: 1.5 creat, cardiac arrhythmia, seizure
IV fluids, + rasburicase (uric acid –> allantoin) OR allopurinol; this helps excretion of salts
Hamolytic anaemia with thrombosis + dark urine in morning suggests what?
What test would confirm
How is it treated?
PNH
Flow cytometry of CD59+55
Blood products + anticoag
