Lankenau Pearls
Hematology & Oncology
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How can you stratify anemia?
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Get reticulocyte count, MCV, RDW
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If appropriately elevated reticulocyte count → bleeding or hemolysis
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If inappropriate reticulocyte count → problem with RBC production and eval MCV
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MCV: size of RBC
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RDW: variety of RBCs - if high, then could be a mix of multiple causes of anemia
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Work-up of anemia: https://twitter.com/WilliamAird4/status/1613152245436276736
What are the main associations of microcytic, normocytic, and macrocytic anemia?
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Microcytic: iron deficiency, thalassemia (VERY low MCV)
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Normocytic: IDA, ACD (kidney, liver), primary bone marrow d/o
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Macrocytic: B12/folate deficiency, alcohol, hypothyroidism, drugs, MDS
What is the work-up for a microcytic/normocytic anemia?
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Iron studies
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If extremely low MCV (<75), then consider thalassemia
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Can use Mentzer index (MCV/RBC count) to distinguish between IDA/thalassemia:
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Mentzer index = MCV/RBC.
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If MI >13, IDA is more likely
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If MI <13, thalassemia is more likely
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What is the work-up for a macrocytic anemia?
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Check B12/folate, TSH, evaluate alcohol use, review medications
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Macrocytic Anemia: https://twitter.com/AaronGoodman33/status/1581753137123057670
How do you distinguish IDA from ACD?
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Ferritin <30 → IDA
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Ferritin 30-100 or 30-500 (in CKD, CHF), low iron, high TIBC → IDA
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Everything else (low TIBC) → ACD
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IDA Work-Up: https://twitter.com/MatthewHoMD/status/1480426316776235012
What are the transfusion goals for anemia?
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Transfuse if Hgb <7 g/dL
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Active ACS, recent heart surgery, transfuse if Hgb <8 g/dL
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Risks of TACO and TRALI
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TACO- Transfusion associated circulatory overload: it is a form of circulatory volume overload that occurs after blood transfusion. The volume transfused and rate of transfusion correlate with risk of TACO
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Risk factors: pre–existing cardiac disease, renal dysfunction, extremes of age <3 or >60, hypoalbuminemia
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Treatment- Great response to diuresis and conservative management
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TRALI- transfusion related acute lung injury
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It is an acute transfusion reaction characterized by respiratory distress, hypoxia, diffuse bilateral infiltrates. Patients often become symptomatic during transfusion or within 6 hours of completing transfusion
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It is not associated with elevated BNP , elevated pulmonary wedge pressure. However may present with fever, hypotension, leukopenia
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Generally not responsive to diuretics
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How much should a blood transfusion raise Hgb?
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1U pRBC should raise Hgb by 1.0 g/dL
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https://www.coreimpodcast.com/2022/01/05/1-to-1-prbc-bump-mind-the-gap-segment/
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What labs should you order if you suspect hemolysis?
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Tbili/dbili (will have increased unconjugated bilirubin in hemolysis)
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LDH (will be high)
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Haptoglobin (will be low)
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Peripheral smear
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Direct antiglobulin (Coombs)
What are the causes of hemolysis?
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Mechanical: mechanical heart valve, Impella (causes shearing)
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Microangiopathic hemolytic anemia (MAHA) (ex. DIC, TTP, HUS, drug-induced)
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Infection (babesia, malaria)
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G6PD, sickle cell, thalassemias
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Autoimmune hemolytic anemia (malignancy, infection, transfusion rxn, drug-induced)
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https://twitter.com/Innov_Medicine/status/1552658980039643136
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https://twitter.com/AaronGoodman33/status/1555303448756686849
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What is a neutropenic fever defined as?
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Fever of 100.4° F and ANC <500/µL (or ANC expected to drop to this range)
What antibiotics are indicated?
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Anti-pseudomonal coverage with cefepime or zosyn
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Only add vancomycin if concern for port infection or skin/soft-tissue infection
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Give abx until fevers have subsided, ANC is >500
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Neutropenic Fever: https://twitter.com/DharSaty/status/1589042672018558977
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https://pubmed.ncbi.nlm.nih.gov/28577308/ (meta-analysis that showed no mortality benefit to including empiric gram-positive coverage)
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What are triggers for a sickle cell crisis?
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Hypoxia, dehydration, cold weather, stress, infections
What is the management of a sickle cell crisis?
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Warmth, oral and IV hydration, pain control with NSAIDs and opioids
What is the transfusion goal in a patient with sickle cell?
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Goal Hgb ~10 g/dL, sometimes lower depending on baseline Hgb
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Risk of hyperhemolysis in SCD patients
What is acute chest syndrome and how do you manage?
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Fever + tachypnea + hypoxia + cough + dyspnea + new pulmonary infiltrate
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Caused by infection, atelectasis, and/or thromboembolism
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Oxygen with goal SaO2 = 100%, incentive spirometry to avoid atelectasis, IV fluids, empiric antibiotics eg CTX/Azithromycin, pain control
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Simple vs exchange transfusion
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https://twitter.com/MedicalGlobe_MG/status/1610977248311377921/photo/1
What are the indications for plasma exchange?
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Acute chest with severe hypoxemia (>6L NC), rapid deterioration or failure to improve
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With plasma exchange, goal Hgb <10 g/dL to avoid hyperviscosity
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What are the best-studied medications to prevent chemotherapy-induced nausea?
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Serotonin antagonist (ondansetron)
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Neurokinin-1 receptor antagonist (aprepitant)
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Glucocorticoids
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Olanzapine
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What should you do if you suspect cord compression?
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Obtain stat MRI with and without, contact neurosurgery and radiation oncology
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Give high-dose dexamethasone (ex. 40 mg IV stat, followed by 10 mg IV q6 hrs)
What is tumor lysis syndrome?
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Rapid breakdown of malignant cells leading to increased serum uric acid, potassium, phosphate, decreased calcium
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Usually 1-5 days after treatment; most commonly in hematologic malignancies or bulky solid tumors
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Can lead to fatal arrhythmias, seizures, tetany
What labs should you trend in tumor lysis syndrome?
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LDH, uric acid, potassium, phosphate, calcium
How do you manage tumor lysis syndrome?
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Fluids
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Rasburicase = directly lowers uric acid
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Prophylaxis: Allopurinol (xanthine oxidase inhibitor, prevents uric acid accumulation)
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Tumor Lysis: https://twitter.com/AaronGoodman33/status/1546182527353647104
What are the first labs to check if a patient presents with elevated calcium?
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Correct calcium for albumin
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Check PTH to determine if PTH dependent or independent
How is hypercalcemia treated?
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Avoid any medications or factors that may contribute including thiazide diuretics, vitamin D toxicity, lithium, calcium supplements
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Isotonic saline @ 200 to 300 mL/hour that is then adjusted to maintain the urine output at 100 to 150 mL/hour; may need to decrease rate in pts with HF or renal failure (can give loop diuretics in this case)
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Calcitonin at initial dose 4 units/kg; check calcium to monitor responses and can re-dose q12 hrs (of note, not beneficial after 48 hours due to tachyphylaxis)
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Bisphosphonates → effective but take up to 2-4 days to kick in, not helpful in acute phase
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How do you follow a solitary pulmonary nodule?
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Nodule 6 mm or less do not need follow-up. Greater than 6 mm - repeat CT in 1 year can be considered.
When would you consider biopsy for a pulmonary nodule?
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Enlarging nodule or red flag (spiculated or lobular, intense uptake on PET scan, diameter >1 cm)
2017 Fleischner Guidelines:
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What are the platelet transfusion goals?
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Transfuse if <10 in most patients, <20 low-risk procedures, <50 if active bleeding or surgeries
How can you classify?
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Decreased production: sepsis, liver disease, bone marrow failure, nutritional deficiencies, HIV, HCV, other viruses
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Increased destruction: HIT, ITP, TTP, DIC, catastrophic APLS, thyroid disease, meds
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Sequestration: splenomegaly
What should you order to work-up low platelets?
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Peripheral smear
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INR, PTT, fibrinogen, D-dimer (rule out DIC)
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INR, AST, ALT (rule out liver pathology, synthetic dysfunction)
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Thrombocytopenia: https://twitter.com/grepmeded/status/1032296056027930625
What score can you use to estimate the likelihood of HIT?
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4T score: platelet count, timing, thrombosis, other causes
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0-3 = low, 4-5 = intermediate, 6-8 = high
What are the 5 classic associations of TTP?
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Thrombocytopenia
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MAHA
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Renal involvement
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Fever
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CNS involvement (TIA or stroke)
What score can you use to estimate likelihood of TTP?
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PLASMIC score: platelet count <30, hemolysis, no active cancer, no hx transplant, MCV<90, INR<1.5, Cr<2.0
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Score 0-4 = low, Score 5 = intermediate, send ADAMSTS13, Score 6-7 = high, send ADAMSTS13 and treat for TTP
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PLASMIC score: https://twitter.com/faheema_hasan/status/1281314898727690240
What is the management of TTP?
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High-doses glucocorticoids (at least 1 g/kg x 3 days)
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Plasma exchange
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Rituximab (monoclonal antibody targeting B cells)
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If no improvement in platelets: caplacizumab (anti-vWF immunoglobulin fragment)
When do you decide to give FFP vs cryo?
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FFP has coag factors, fibrinogen, volume 250-600 cc whereas cryo is very concentrated FFP so more fibrinogen but fewer factors, volume 10-20 cc
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FFP vs. cryo: https://twitter.com/LKSOM_Medicine/status/1481802671208161281
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What are standard inpatient DVT ppx and why would you use particular ones?
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Lovenox (enoxaparin) aka LMWH: 40 mg/day (more predictable dosing and monitoring)
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Heparin: 5000U q8 hr (in CrCl <30)
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SCDs: pts with bleeding
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Nothing: in pts who are already on DOAC or warfarin (therapeutic AC) for other reasons