Haematology Flashcards
1
Q
What is the normal range for Hb in females?
A
11.5 - 14.5 g/dl
2
Q
What is the normal range for MCV?
A
77-95 fl
3
Q
What is the normal range for haematocrit?
A
0.37 - 0.47
4
Q
What is the normal range for WCC?
A
4 - 11 x 10(9)/L
5
Q
What is the normal range for platelets?
A
140-400 x 10(9)/L
6
Q
Why is reticulocyte count relevant in anaemia?
A
Absence of an appropriate reticulocytosis in the setting of anaemia suggests impaired RBC production
7
Q
What is APTT?
A
Activated Partial Thromboplastin Time
8
Q
What does APTT measure?
A
Intrinsic pathway - factors XII, XI, IX, VIII
9
Q
What causes a prolonged APTT?
A
Factor deficiency
Heparin treatment
10
Q
What does prothrombin time measure?
A
Extrinsic pathway
11
Q
What else is a long prothrombin time called?
A
High INR
12
Q
What are the causes of prolonged prothrombin time?
A
Vitamin K deficiency
Anticoagulation with warfarin
Factor deficiency
13
Q
What are D dimers?
A
Fibrinogen-fibrin degradation products
14
Q
What is polycythaemia?
A
Increase in total mass of red blood cells in body
15
Q
What is erythrocytosis?
A
Increase in concentration of red blood cells
16
Q
What is primary polycythaemia?
A
Polycythaemia rubra vera - myeloproliferative
17
Q
What causes secondary polycythaemia?
A
Driven by erythropoietin production
18
Q
When is secondary polycythaemia physiologically appropriate?
A
High altitude Chronic cor pulmonale Cyanotic congenital heart disease Hypo ventilation Abnormal Hbs
19
Q
When is secondary polycythaemia physiologically inappropriate?
A
Renal: RCC, haemangioma, post-transplant, polycystic
Hepatocellular carcinoma
Others - cerebellar haemangioma, uterine tumours, Cushing’s syndrome, EPO abuse, androgen abuse
20
Q
What are the causes of microcytic anaemia?
A
Iron deficiency Anaemia of chronic disease Haemoglobinopathy Vit A or B6 deficiency Sideroblastic anaemia
21
Q
What are the causes of folate deficiency?
A
Poor diet
Increased needs
Malabsorption - coeliac disease, jejunal resection
22
Q
What type of anaemia do vit B12 and folate deficiency cause?
A
Macrocytic
23
Q
What drugs cause increased MCV?
A
Sulfasalazine Alcohol Methotrexate Valproate Cholestyramine Some cytotoxic drugs
24
Q
What are the different types of haemolysis?
A
Hereditary or acquired
Immune or non-immune
Extravascular or intravascular
25
What are the causes of AIHA (autoimmune haemolytic anaemia)?
```
Primary
CLL
Drugs
SLE
EBV
```
26
What are the causes of non-immune haemolytic anaemia?
Hypersplenism
Prosthetic heart valves
Sepsis
Malaria
27
What are the causes of mechanical haemolysis?
Cardiac haemolysis
AV malformations
Microangiopathic haemolytic anaemia eg TTP, DIC, malignancy, vasculitis, pre-eclampsia, renal vascular disorders
28
What are the causes of normocytic anaemia?
All of previous causes
Blood loss
Anaemia of chronic disease
Starvation or anorexia nervosa
29
What is the normal range for Hb in males?
12.5 - 15.5 g/dl
30
What does a raised reticulocyte count in anaemia suggest?
| .
Active marrow response ... Not necessarily haemolysis
31
What should you do if a platelet count comes back low?
Repeat and send full clotting screen
32
What drugs should be avoided in thrombocytopenia?
Aspirin
| NSAIDs
33
What drugs can cause neutropenia?
```
Antipsychotics
Antidepressants
Anti-inflammatory
Antithyroid
Chemotherapy
```
34
What is the treatment for ITP?
Steroids
35
How do you reverse warfarin?
5mg IV vitamin K
36
How do you immediately reverse warfarin?
Prothrombin complex and vitamin K
37
What is the dose of FFP?
10 - 15ml/kg
38
What is virchow's triad?
Hypercoagulability
Vascular damage
Stasis
39
What factors contribute to the Wells score?
```
Active cancer
Immobilisation > 3 days
Localised tenderness along DV
Entire leg swollen
Calf swelling > 3cm
Pitting oedema
Collateral superficial veins
Likely alternative diagnosis
```
40
What wells score indicates the need for imaging?
Moderate or high (>1) in patients with other inter current illness
41
What score is a high wells score?
3 or more
42
When is testing D dimers a sensitive test?
To exclude DVT in non-hospitalised patients with a low risk score
43
Why are D dimers not used for patients in hospital?
They are raised in any inter current ilness and so not recommended - not specific
44
When is the probability of PE high?
A + B...
A) clinical features (SOB, tachypnoea, pleuritic chest pain, haemoptysis, syncope)
B) absence of another reasonable clinical explanation or presence of a major risk factor
45
What types of malignancy are major risk factors for PE?
Abdominal or pelvic
| Advanced or metastatic
46
What is the first line imaging technique for suspected PE?
CTPA
Including intermediate or high probability in pregnancy
47
What other imaging techniques are used for suspected PE?
VQ scan
Echo
Leg USS
Pulmonary angiogram
48
When is thrombolysis indicated for PE?
Massive life-threatening PE
Haemodynamic compromise
Significant right ventricular dysfunction
49
How do you use heparin when commencing warfarin?
Continue heparin for minimum of 4 days until INR>2 for 2 consecutive days
50
What is the target INR for PE and DVT?
2. 5
| 3. 5 if recurrent VTE whilst on warfarin
51
What is the relationship of proximal DVT and PE?
50% of patients with proximal DVT have asymptomatic pulmonary embolism at the time of diagnosis
52
What proportion of patients with PE have a DVT at the time of diagnosis?
40-50%
53
How long should warfarin be continued after proximal DVT or PE?
At least 3 months
54
When should dalteparin be used in medical patients?
```
Reduce mobility with one of:
A) severe cardiac failure
B) acute respiratory failur
C) active cancer or inflammatory disease
D) acute infection/inflammation plus >75y, chronic heart or resp failure, previous VTE, obesity, COCP, varicose veins
```
55
What are the contraindications to Dalteparin?
Known bleeding disorder or platelets
56
What are the contraindications to TED stockings?
```
Dermatitis
Gangrene, leg ulcers
Symptomatic PVD
Cellulitis
Peripheral neuropathy
Massive oedema of legs or pulmonary oedema from CCF
```
57
Over how long should red cells be transfused?
Within 4 hr of removal from fridge
| Ideally over 2-3 hours
58
How is the use by date of blood products relevant in practice?
Transfusion must be STARTED by midnight on day of use by
59
How are red cells stored?
Fridge
| 2-6 degrees
60
How are platelets stored?
Room temperature
61
What antigens are found on red cells of a patient with blood group A?
A
62
What antibodies are found in the plasma of a patient with blood group B?
Anti-A
63
What antibodies are found in the plasma of a patient with blood group O?
Anti-A and Anti-B
64
Why does blood have to be ABO compatible?
Transfusion of only a few mls of incompatible blood can trigger a massive immune response leading to shock and DIC
Patients may die from circulatory collapse, severe bleeding or renal failure within a few hours
65
When can RhD positive cells be given to a RhD negative patient?
In an emergency situation
| If female older than 50 or male older than 16
66
What are the Hb levels that indicate the need for red cell transfusion?
No CVS disease maintain at 70-90g/L
| Known/likely CVS disease maintain at 90-100g/L
67
How are platelets for transfusion collected?
Pooled platelets - from whole blood that has been centrifuged
Apheresis - specially collected from a donor
68
When are platelet transfusions contraindicated?
TTP
| HIT
69
When is FFP given?
Coagulation deficiencies / DIC
| TTP
70
What is cryoprecipitate?
Contains cryoproteins (clotting factors)
71
When do blood giving sets need to be changed?
After 8 hours or 2 units
| If the blood component being transfused changes, so should the giving set
72
How long does blood traceability need to be maintained?
Minimum 30 years
73
What are SABREs and what is their significance?
Serious adverse blood related events
| Must be reported to the MHRA within 7 days of their occurrence
74
What is SHOT?
Serious Hazards Of Transfusion
| Anonymous national scheme for reporting adverse blood incidents or near miss events
75
What is positive identification for transfusion?
Full name + DOB + hospital number
| Ask the patient and ALWAYS check the ID band
76
When should the massive haemorrhage protocol be activated?
50% total blood volume loss in 3 hours
Total blood volume loss in less than 24 hours
Rate of loss 150ml/min
If 4 units of red cells have been transfused in an hour and similar further need is anticipated
77
What does activating the massive haemorrhage protocol mean?
Blood components will be prepared at regular intervals of 15mins until the MH is stood down by the clinical team
78
What is autologous transfusion?
Donor and recipient are the same person
79
How can transfusion requirements be reduced perioperatively?
Pre-op diagnosis and treatment of anaemia
Plan for intra-op cell salvage
Maintain normothermia
Careful positioning of patient during surgery
80
What is intra-operative cell salvage?
Collection and re-infusion of blood aspirated from the operative field during surgery
81
What is post-operative cell salvage?
Collection of blood from surgical drains followed by re-infusion
82
What are the potential early transfusion reactions?
```
Acute haemolytic reactions
Anaphylaxis
Bacterial contamination
Febrile reactions
Allergic reactions
Fluid overload
TRALI
```
83
What are the potential delayed transfusion reactions?
Infections
Iron overload
Graft versus host disease
Post-transfusion purpura
84
What should you do if a complication occurs during transfusion?
Stop the transfusion
85
How much does 1 unit of red cells increase Hb?
10g/L
86
How much does 1 adult dose of platelets increase platelet count by?
20-30
87
What is the threshold for transfusion in a chemo patient?
80
88
What is the lowest platelet count can be for most procedures?
50
89
What is a Hickman line?
Incision in jugular vein and chest wall
| Done under sedation/GA
90
What prophylaxis needs to be given to chemo patients?
Allopurinol
Antifungals - itraconazole
Co-trimoxazole
Antiviral - aciclovir
91
What is leukaemia?
Increase in number of white blood cells
92
Which leukaemia is more common in children?
Acute lymphoid leukaemia (ALL)
93
How does acute leukaemia present?
Rapid onset of symptoms
| Tiredness, fever, sweats
94
What are the signs of marrow failure?
Normal cells are lost:
RBC - tired, pale, short of breath
WBC - infection
Platelets - bleeding and bruising
95
What does the bone marrow look like in acute leukaemia?
Hyper cellular
Often packed with blasts
Auer rods = AML
96
What does the FBC show in acute leukaemia?
Normocytic normochromic anaemia
Low platelet count
WCC may by low, normal or high
97
What is the Philadelphia chromosome?
Translocation 9 to 22
| Characteristic of ALL
98
When is bone marrow transplant used in acute leukaemia?
During 1st remission in disease with poor prognosis
99
How is bone marrow transplantation done?
Destroy leukaemic cells and the immune system by total body irradiation
Repopulate marrow by transplantation from a matched donor, infused IV
100
What is ALL?
Acute lymphoblastic leukaemia
Malignancy of lymphoid cells, affecting B or T lymphocyte lines
Uncontrolled proliferation of immature blast cells leading to marrow failure and tissue infiltration
101
In which type of leukaemia is the Philadelphia chromosome identified?
ALL
And
CML
102
How does the Philadelphia chromosome affect prognosis?
If present in ALL, means worse prognosis
| If present in CML (80% patients) indicates better prognosis
103
How does CML present?
```
Weight loss
Tiredness
Fever
Sweats
Gout
```
104
What do investigations show in CML?
Normochromic normocytic anaemia
BM hyper cellular
Cytogenetics: t(9;22)
105
What is the treatment for CML?
Imatinib - tyrosine kinase inhibitor
106
What is the median survival rate for CML?
5-6y
107
What is the most common form of leukaemia?
CLL
108
How does CLL present?
```
Often asymptomatic, incidental finding on FBC
Anaemia
Infection-prone
Weight loss, sweats, anorexia
Enlarged, nontender rubbery nodes
Soleno or hepatomegaly
```
109
What are the potential complications of CLL?
Autoimmune haemolysis
Marrow infiltration - low Hb, neutrophils and platelets
Increased infection rate
110
What are the common causes of death from CLL?
Infection
| Transformation to aggressive lymphoma
111
What is the prognosis for CLL?
One third never progress
One third progress slowly
One third progress actively
112
What is lymphoma?
Malignant proliferation of lymphocytes (B and T cell neoplasms)
Accumulate in lymph nodes and can also be found in peripheral blood or infiltrate organs = extra-nodal areas
113
What is the difference between lymphoma and leukaemia?
Affecting mainly bone marrow = leukaemia
| Predominantly nodal/organ based = lymphoma
114
What type of cells do you get in Hodgkin's lymphoma?
Reed-Sternberg cells
115
How does Hodgkin's lymphoma present?
Enlarged, painless, non-tender, rubbery nodes
| Systemic (B) symptoms: fever, weight loss, night sweats, pruritis, lethargy
116
What are the signs of Hodgkin's lymphoma?
Lymph node enlargement
Cachexia
Anaemia
Spleno-/hepatomegaly
117
How might Hodgkin's lymphoma present as an acute emergency?
SVCO due to mediastinal node involvement
118
How do you diagnose Hodgkin's lymphoma?
Lymph node excision biopsy if possible
| FBC, blood film, ESR, LFT, LDH, urate, calcium
119
What staging system is used for lymphoma?
Ann Arbor
120
What investigations are required for staging of lymphoma?
CXR
CT thorax, abdo, pelvis
Marrow biopsy if B symptoms
121
Describe Ann Arbor staging
1- single lymph node region
2- 2 or more nodal areas, but same side of diaphragm
3- nodes on both sides of diaphragm
4- spread beyond lymph nodes e.g. Liver or marrow
A or B - systemic symptoms
122
What are the B symptoms in Ann Arbor staging?
Weight loss >10% in last 6 months
Unexplained fever >38
Night sweats needing change of clothes
123
What is the treatment for Hodgkin's lymphoma?
Chemoradiotherapy
Longer courses of chemo for higher stages
Relapsed disease - high-dose chemo with peripheral stem cell transplantation
124
What is the prognosis for Hodgkin's lymphoma?
5y survival 95% in I-A
125
What is non-Hodgkin's lymphoma?
All lymphomas without R-S cells
126
What is the most common NHL?
Diffuse large B cell lymphoma
127
What are the extra-nodal presentations of NHL?
Gastric MALT
Non-MALT gastric lymphoma
Small bowel lymphoma
128
How do low grade and high grade lymphomas differ?
Low grade often incurable and widely disseminated, but may not require treatment if asymptomatic
High grade more aggressive but often curable
129
How does high grade lymphoma present?
Rapidly-enlarging lymphadenopathy and systemic symptoms
130
Give some examples of high grade lymphomas
Burkitt's lymphoma
Lymphoblastic lymphomas
Diffuse large B cell lymphoma
131
What factors indicate worse prognosis in NHL?
```
Age>60
Systemic symptoms
Bulky disease
Raised LDH
Disseminated disease
```
132
What is myeloma?
Abnormal proliferation of a single clone of plasma or lymphoplasmacytic cells
Leading to the secretion of Ig causing the dysfunction of many organs
133
How is Ig detected in myeloma?
Seen as a monoclonal band (paraprotein) on serum/urine electrophoresis
134
Why are myeloma patients susceptible to infection?
Other Ig levels are low
135
What is Bence Jones protein?
Free Ig light chains filtered by the kidneys
| Detected in urine in 2/3 cases
136
What is the peak age for diagnosis of myeloma?
70
137
What are the manifestations of myeloma?
Osteolytic bone lesions - back pain, fractures, hypercalcaemia
Anaemia, neutropenia, thrombocytopenia
Recurrent bacterial infections
Renal impairment
138
Why do patients get renal impairment in myeloma?
Light chain deposition
139
Why may myeloma patients get pancytopenia?
Marrow infiltration by plasma cells
140
What does CRAB stand for in relation to myeloma?
Calcium (high)
Renal impairment
Anaemia
Bone/Back pain
141
What do X-rays show in myeloma?
Lytic 'punched out' lesions
| Eg pepper pot skull, vertebral collapse, fractures or osteoporosis
142
How do you diagnose myeloma?
1. Monoclonal protein band on serum or urine electrophoresis
2. Plasma cells increased on marrow biopsy
3. Evidence of end-organ damage eg renal, anaemia, hypercalcaemia
4. Bone lesions - skeletal survey
143
What supportive treatment is used for myeloma?
```
Analgesia (avoid NSAIDs as renal failure)
Bisphosphonate
Local radiotherapy
Transfusion/EPO for anaemia
Fluid intake
Antibiotics for infection
```
144
What are the common causes of death in myeloma?
Infection
| Renal failure
145
What factors indicate worse prognosis in myeloma?
>2 osteopathic lesions
| Hb
146
What are the complications of myeloma?
Hypercalcaemia
Spinal cord compression
Hyperviscosity
AKI
147
What are the symptoms of hyperviscosity?
Reduced cognition
Blurred vision
Bleeding
148
What is MGUS?
Monoclonal gammopathy of uncertain significance
Paraprotein present in serum, but there is no myeloma
Some develop myeloma or lymphoma
