Miscellaneous Flashcards
AC trial at Medstar
RCT double blind study comparing ASA vs placebo for 3 years w/ end goal monitoring of decreased recurrence of breast cancer following standard chemotherapy regimens
Palbociclib benefit for breast cancer
When combined w/ endocrine therapy, increased PFS
Consideration of long term anastrazole for post chemotherapy breast cancer
If patient is post menopausal and had low grade disease, unlikely to have great benefit
If high grade disease or premenopausal, recommend continuation for 10 years
Mondoor’s disease
Superficial thrombophlebitis of the veins of the anterior chest wall
Capecitabine cycles for metastatic breast cancer
Oral regimen taken for 14 days followed by 7 day break
Total cycle length is 21 days
Stauffer’s Syndrome
Signs of cholestasis unrelated to tumor infiltration of the liver that resolves after RCC resection
Sarcoma that requires full body scanning
Myeloid lipoid sarcoma; requires full body CT, MRI spine, MRI brain
Merkel Cell Cancer general concept for therapy
Carboplatin + Etopiside (like small cell lung cancer); additionally, they are now trying PD-1 inhibitor therapies
Ravulizumab
Anti-C5 antibody used to atypical HUS, PNH in the US; associated with increased risk for meningococcal infections due to decrease formation of C5-9 complex
Anticoagulant w/ the best bleeding profile
Eliquis
Thrombin positively feedbacks what factors in the coagulation cascade?
II, V, XI, XIII
-Is partly why Factor XII, PK, and HMWK deficiencies don’t bleed since XI can still be activated
Antithrombin inhibits what molecules?
Thrombin (duh), Factor IXa, and Xa; irreversibly binds
-Also factors XIa and XIIa to a small extent
Protein C function
Cleaves cofactors Va and VIIIa to reduce their function; free protein S is a cofactor for activated protein C function
What are some of our natural anticoagulant pathways?
Antithrombin
Protein C, S
Tissue Factor Pathway Inhibitor (TFPI)
Plasminogen
Treatment for Factor VIII inhibitor
Activated Factor VII
Additionally, steroids + cyclophosphamide to eliminate the inhibitor
Antiphospholipid antibodies will prolong with coagulation time?
PTT
When is the PFA inaccurate?
When platelet count is <100 or if Hcrt is <30
Causes of acquired vWD
MGUS - treatable w/ IVIG
Hypothyroidism - type I due to decreased production
MPNs - type II due to sticky platelets that don’t bind vWF
Valvular disorders (Heide’s)
LVADs
Wilm’s tumors
Cause of acquired Factor X deficiency
Amyloidosis - actively removes Factor X from plasma; fix with replacement
What can patient’s with a lupus inhibitor also have?
Anti Factor II antibody
What lab can be increased with SS crisis?
AST; due to reserve in RBCs
Bendamustine ADRs
Fever at night, increased Cr NOT DUE TO TLS, hair loss, nausea
Rituxan infusion rate
It is slowly increased every 30minutes to ensure no reaction; typically, this won’t occur until the 2nd or 3rd increase
Patient with a provoked DVT who still gets tested and has a positive hypercoagulable screen
Does not change management; repeat testing after 3 months of treatment for provoked DVT and test when off anticoagulation
Labs to check for thrombophilia
LA ACL Anti-B2 glycoprotein FVL Prothombin G20201A Protein S Free s antigen Protein C Antithrombin III activity
What to do with patient who is heterozygous for BOTH FVL and prothrombin mutations?
Anticoagulate; if positive for just one, don’t
Acquired hemophilia deficiencies
Acquired deficiency: • Liver disease (C, S, AT) • Warfarin therapy (C, S) • Estrogens, pregnancy (S) • Inflammatory diseases (S) • Heparin therapy (AT) • Acute thrombosis (S, AT)
Bleeding disorder that is usually benign but most commonly presents as excessive intraoperative bleeding
Factor XI deficiency
Diagnosis: Prolonged aPTT, low Factor XIa level
Tx: Antifibrinolytics, FFP prior to surgery
Factor VII deficiency
Mucocutaneous or surgical bleeding but rarely presents as thrombosis
Tx with rVIIa
Plasma dyscrasias can be associated with a deficiency of which coagulation factor?
Factor X
Can also be AR inherited (1:500k)
Levels are well associated with symptoms
Tx: FX concentrate, PCC, FFP, treatment of plasma cell disorder
Factor V deficiency
Has prolonged aPTT, PT, normal thrombin time
Can treat with platelets because platelet granules contain factor V
Bleeding from umbilical stump or sudden ICH
Factor XIII deficiency; AR genes coding for catalytic A subunit
Can also present as poor wound healing or pregnancy loss
Dx: Clot solubility test, Factor XIII assay, genetic testing
Treatment for Factor XIII deficiency
Recombinant Factor XIIIa subunit OR pdFXIII if known to have B subunit mutation
Can also use FFP if not available
*****Give monthly prophylactic Factor XIII treatment in patients with FXIII level <10% to decrease risk of spontaneous ICH
Prothrombin deficiency
Poor correlation with levels and clinical bleeds
Dx: Same to factor V deficiencies; confirm with prothrombin activity assay, prothrombin antigen level, genetic testing
**Need to rule out acquired deficiency and check for antiprothrombin antibodies
Tx: PCC q2-3days, pts only need prophylaxis with history of severe bleeding, prothrombin levels <10%
Hypofibrinogenemia
Homozygous = No fribrinogen Heterozygous= Hypofibrinogenemia
Tx: Cryo, FFP, prophylaxis in only severe cases
Dysfibrinogenemia
Actually associated w/ increase risk of thrombosis (20-25%)
Second most common inheritable bleeding disorder
HHT; AD inherited
95% have severe recurrent mucocutaneous bleeding; many patients also have liver, lung, brain vascular malformations that are at increased risk for hemorrhage
Tx: Iron infusions + Antifibrinolytics + Local ablative procedures + Antiangiogenic therapies (bevacizumab)
