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MKSAP 2019 > Hematology > Flashcards

Hematology Flashcards

1
Q

Causes of Neutrophilia

A
  • CLL
  • Smoking
  • Steroid
  • Lithium
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2
Q

Indication of treatment of Polycythemia Vera

A

With additional risk factors including
- Age older than 60 years or
- h/o thromboembolic event

Should receive cytoeductive therapy with hydroxyurea or interferon alpha. PLUS ASPIRIN.
(Ruxolitinib for intolerant to first line agent or resistant PV)

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3
Q

Chemotherapy induced neutropenia typically occurs within…

A

5 to 15 days following chemotherapy.

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4
Q

Prophylactic Indication of G-CSF

A
  • high risk patients (undergoing allogeneic stem cell transplantation or receiving induction chemo for acute leukemia) of neutropenia
  • as secondary prophylaxis in patient with previous episode of febrile neutropenia

Usually given on day 2 of chemotherapy.

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5
Q

Survivors of pediatric leukemia (typically acute lymphoblastic leukemia) are at increased risk of developing

A
  • metabolic syndrome
  • so screening for dyslipidemia, diabetes mellitus, and hypertension is recommended.
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6
Q

Key Points

A

The dilute Russell viper venom time is an assay used to confirm the presence of a lupus anticoagulant (LAC), which might be a diagnostic consideration if the prolonged aPTT fails to correct following a one-to-one mixing study.

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7
Q

What is the diagnosis?
- Chronic Hypochromic Microcytic Anemia
- Target cells of peripheral blood smear
- Normal hemoglobin electrophoresis

A

Alpha Thalessemia Trait.

“Silent carrier” do not have anemia.

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8
Q

Key Point

A

Patients with β-thalassemia have chronic microcytic anemia, target cells on the peripheral blood smear, a reduced hemoglobin A level, and elevated levels of hemoglobin F and hemoglobin A2 on hemoglobin electrophoresis.

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9
Q

Key Points

A

The hallmark of chronic myeloid leukemia is the Philadelphia chromosome, a reciprocal translocation of the ABL gene on chromosome 9 to the BCR gene on chromosome 22, designated as t(9;22).

A tyrosine kinase inhibitor such as imatinib is considered first-line treatment for patients with chronic myeloid leukemia diagnosed in the chronic phase (<10% blasts in the bone marrow).

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10
Q

Indication of Steroid in ITP

A
  • Platelet count less than 30K who are asymptomatic or
  • who have mucocutaneous bleeding

course (<6 weeks) of prednisone or dexamethasone. The response to intravenous immune globulin is faster and may be indicated in patients with more severe thrombocytopenia and life-threatening bleeding.

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11
Q

Indication of platelet transfusion in ITP

A

If only patient is bleeding

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12
Q

Treatment of metastatic Non Small Cell Lung cancer with ALK translocation

A

Alectinib

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13
Q

Patient taking aromatase inhibitor without active cancer

A
  • should take calcium and vitamin D
  • should get annual DEXA scan
  • confirmed Osteoporosis>start Alendronate

But if patient is on active anti-cancer therapy, patient should be started on Alendronate/bisphosphonate irrespective of osteoporosis

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14
Q

Key Point

A

CLL without significant symptoms, bulky adenopathy or cytopenias shouldn’t be initiated on treatment.

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15
Q

Gastroesophageal tumor should be evaluated for expression of

A

Human Growth Factor 2 (HER2)

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16
Q

Melanoma should be evaluated for expression of

A

BRAF mutation

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17
Q

Key Point

A
  • Elevated CEA level indicates worse prognosis for patient at any stage of colon cancer.
  • Rising CEA level during surveillance period after resection indicates recurrence.
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18
Q

Indication of Lung cancer screening

A
  • 50-80 years age
  • 20 Pack year
  • quit less than 15 years ago

With Low dose Chest CT annually.

19
Q

Typical Findings in DIC

A
  • thrombocytopenia
  • prolonged coagulation measures
  • hypofibrinogenemia
  • elevated d dimer level
20
Q

Key Point

A

For patients with pulmonary embolism (PE) with a low risk for complications, the American Society of Hematology guideline suggests offering home treatment over hospital treatment.

Can use Pulmonary Embolism Severity Index, to predict outcome but not replace clinical judgement.

21
Q

Indication for platelet transfusion

A
  • patients with platelet counts less than 50,000/μL (50 × 109/L) before undergoing invasive procedures or general surgery with a significant risk of bleeding.
22
Q

Key Points of Drug induced Neutropenia

A

Drug-induced neutropenia results from
- impairment of normal granulopoiesis in the bone marrow or
- through a drug-dependent, antibody-mediated immune destruction of circulating neutrophils.

The thionamides propylthiouracil and methimazole are among the drugs known to cause agranulocytosis; although the overall prevalence is low (around 0.5%), the risk is higher compared with other drug classes.
- Agranulocytosis is more likely to occur within the first 3 months of drug initiation
- more common in women
- appears to be dose related with methimazole.
- The ANC should recover within 1 to 3 weeks after discontinuing the medication.

23
Q

Key Points

A

Never test for protein c, protein s and Antithrombin II (Hypercoagulable workup0 during inpatient settings.

24
Q

Patient with Heparin Induced thrombocytopenia can be switched to

A
  • If renal function is normal, either Apixaban or Rivaroxaban
  • Fondaparinux or Argatroban can also be considered.
25
Q

Key Points about Aplastic anemia

A

Allogeneic hematopoietic stem cell transplantation is the preferred treatment for aplastic anemia in younger patients who have an HLA-matched stem cell donor.

In patients older than 50 years and in younger patients without a suitable stem cell donor, aplastic anemia is treated by immunosuppression with antithymocyte globulin, cyclosporine, and prednisone.

26
Q

Key Points about Warfarin and INR

A
  • Patients taking warfarin with a supratherapeutic INR less than 10 and no signs of bleeding, warfarin should be withheld until the INR returns to the therapeutic range
  • For INR elevation greater than 10 without bleeding, vitamin K is recommended in addition to withholding warfarin
  • If the INR is elevated and life-threatening bleeding is present, then warfarin is withheld, and vitamin K and a prothrombin complex concentrate should be administered.
27
Q

Agent of choice for warfarin reversal

A

4-factor PCC is the preferred agent for warfarin reversal when a reversal agent is necessary.

Fresh frozen plasma (FFP) is not the preferred agent when treatment of life-threatening bleeding is necessary for a patient with a supratherapeutic INR. 4-Factor PCC has been found to be noninferior to FFP in the treatment of life-threatening bleeding. Additionally, 4-factor PCC has a faster infusion time, more rapid reversal of INR, and lower risk of volume overload.

28
Q

Key Points about Anemia of Kidney disease.

A
  • normochromic and hypoproliferative and typically has normal erythrocyte morphology on peripheral blood smear. (Echinocytes can be seen sometimes)

The anemia of kidney disease is associated with a low or inappropriately low-normal erythropoietin level

29
Q

“… score” is calculated to determine use of anticoagulants in cancer patients in outpatient.

A
  • Khorana Score

In the absence of contraindications, outpatients with cancer at high risk of VTE (Khorana score of 2 or higher before starting a new systemic chemotherapy regimen) may be offered thromboprophylaxis with apixaban, rivaroxaban, or low-molecular-weight heparin.

30
Q

Key Points

A

If patient has isolated thrombocytopenia without other symptoms; think of immune thrombocytopenia. Check for:
- HIV
- HCV
- H pylori (test if patient from endemic region)

  • Patients with HIV infection may have ITP independent of HIV viral load or CD4 cell count and may be otherwise asymptomatic.
31
Q

Reversal of Apixaban, Rivaroxaban, and Edoxaban

A

Andexanet alfa is a recombinant modified factor Xa that competes for binding to factor X with the factor Xa inhibitors

32
Q

Reversal of Dabigatran

A

Idarucizumab is safe and effective in reversing the anticoagulant effects of dabigatran.

  • if not able to get Idarucizumab, HD is an option (take 4 hours)
33
Q

MCV greater than 110-115

A
  • folic acid and B12 deficiency
  • hydroxyurea
  • antiretrovirals HIV
34
Q

Score used to r/o PE

A

Pulmonary Embolism Rule-Out Criteria

  • Age <50 y, Initial heart rate <100 beats/min, Initial oxygen saturation >94% on room air, No unilateral leg swelling, No hemoptysis, No surgery or trauma within 4 weeks, No history of venous thromboembolism, No estrogen use.

A meta-analysis of 12 studies showed that if the PERC is used, only 0.3% of PEs would be missed and 22% of D-dimer testing would have been safely avoided.

35
Q

Target hemoglobin before surgery sickle cell disease, particularly hemoglobin SS disease

A

10 g/dL

SDD particulary hb SS disease, benefit from preoperative simple transfusion to achieve a hemoglobin level of 10 g/dL (100 g/L).

36
Q

Treatment of thrombotic thrombocytopenia purpura:

A

Plasma exchange, glucocorticoids, and rituximab.

Do not choose plasmapheresis, plasma should be exchanged! ; Performing plasmapheresis with non-plasma replacement, such as saline and albumin, will remove the autoantibody but does not correct the ADAMTS13 deficiency. Plasma exchange and immunosuppressive therapy are crucial to remove the autoantibody, replace the deficient ADAMTS13, and prevent the formation of new autoantibody.

37
Q

Indication of treatment of hemochromatosis

A

The 2019 guideline from the American College of Gastroenterology (ACG) recommends treatment in patients with
- homozygous C282Y mutations with
- serum ferritin greater than 300 ng/mL (300 μg/L) in men and greater than 200 ng/mL (200 μg/L) in women
- transferrin saturation of 45% or more.

Other sources recommend observation for serum ferritin levels less than 500 ng/mL (500 μg/L) regardless of genotype.

If Heterozygous- no need to treat or monitor

38
Q

Treatment is indicated for Superficial Vein Thrombosis

A
  • thrombus is 5 cm or greater in length or
  • is close to the deep venous system or
  • if other thrombophilic risk factors are present.

Total Duration is 6 weeks.

If non met>f/u in 1 week>repeat Duplex.

39
Q

Key Points

A

Erythropoietin is important in the treatment of the anemia of chronic kidney disease (CKD) and is often needed in patients with end-stage kidney disease receiving dialysis. Guidelines recommend that erythropoietin-stimulating agents be withheld in patients with CKD not requiring dialysis who have a hemoglobin level greater than 10 g/dL (100 g/L).

40
Q

Indication of starting Chelation therapy in thalassemia major.

A
  • serum ferritin level exceeds 1000 ng/mL (1000 μg/L)
  • after approximately 15 to 20 units of blood have been transfused, or
  • with evidence of organ deposition (>3 mg of iron per gram dry weight in the liver or cardiac T2* <20 milliseconds on MRI).
41
Q

Anticoagulation of choice for APLS

A

LMWH followed by Warfarin.

42
Q

Key Points

A

In patients taking dual antiplatelet therapy following coronary revascularization with significant hemorrhage, the best strategy is to discontinue the P2Y12 receptor (Plavix, Clopidogrel) antagonist and continue aspirin.

43
Q

Key Points

A

The myelodysplastic syndromes are clonal stem cell disorders with ineffective hematopoiesis leading to dysplastic, hypercellular bone marrow and peripheral blood cytopenias.

Patients with the 5q− cytogenetic abnormality who are transfusion dependent can be treated with lenalidomide to decrease transfusion needs.

MKSAP 2019 (2 decks)

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