Hematology Review May 15 2009

1. Hematology ReviewMay 15 2009

2. Hematology Review • Vignette tips • Pictures • Laboratories Tests • Treatment

3. Anemia • Iron deficinecy • Macrocytic B12,Folate,MDS • Anemia of chronic diseases • Hemolytic • Autoimmune • TTP/HUS • Drug induced • Hemoglobinopathies

4. Anemia • Iron deficiency

5. Iron deficiency • Vignette tips • Pictures • Laboratories Tests • Low Iron • High IBC • Low Ferritin • Treatment • Give Iron • LOOK FOR SOURCE OF BLEEDING

6. Iron deficiency

7. Iron deficiency Low Iron High IBC Low Ferritin

8. Macrocytic B12,Folate,MDS • Vignette tips • Pictures • Laboratories Tests • Treatment • Never answer folate alone as initial therapy • Look for associated disease

11. Anemia • Autoimmune Hemolytic Anemia

12. Anemia • Hemoglobinopathies

13. Case 3

14. Case 3

15. Thrombocytopenia • ITP • HIV • TTP/HUS • HIT • Other drugs

16. Thrombocytopenia • TTP

17. HIT • Clinical diagnosis • Laboratory helps but does not always • When in doubt DTI

18. Coagulopathies • Hemophilia • X linked disorder • Von Willebrand disease • Type I • Type II and IIn • Type III • Platelet function abnormalities • Aspirin

19. Hemophilia

20. Thrombophilias • Protein C and S • Antithrombin III • Prothrombin mutations • Factor V Leiden • Antiphospholipid syndrome

21. Antiphospholipid syndrome • Acquired thrombophilic condition • Vascular thrombosis or recurrent pregnancy loss • Presence of Antibodies that recognize phospholipids or PL binding proteins.

22. Sapporo Criteria

23. Lupus anticoagulant testing

24. Lupus anticoagulant testing

25. ELISA

26. Myeloproliferative disorder • P.Vera Jak2 • CML Imatinib,Desatinib, • ET • Myelofibrosis

27. Myelodisplasia • Definition • Chromosomes • 5q Lenalidomide (Revlimid) • EpigeneticsDecitabine, 5 Azacytidine

28. Drugs

29. Laboaratory • Prolonged PT and PTT • MCV • Retic • Fe studies

30. Blood Bank • Type and Crossmatch • Transfusion reactions

31. Hematological malignancies • Acute leukemia • If DIC think APL/M3/Promyelocytic leukemia • If extramedulary manifestation think monocytic/monoblastic M4 M5 • If Auer rods call it AML • If no Auer Rods cannot call it AML or ALL

32. Hematological malignanciesAcute leukemia

33. Hematological malignanciesLymphoma • Low grade lymphomas • Indolent/No cure/watchfull wait is an option/Rituximab • CLL • Follicular • Intermediate • More aggressive, chemotherapy can cure/Rituximab • Diffuse large cell • Aggressive • Burkitt’s

34. Hematological malignanciesLymphoma

35. Hematological malignanciesMyeloma • Kidney • Bone • Amyloid • Anemia • Thalidomide, Revlimid, Bortezomib, Transplant • Biphosphonates • Osteonecrosis of the jaw

36. DVT/PE • Hypercoagulable states • Except for APLS and possibly pregnancy recommendations rarely affect management • Do not ask for ATIII if pt on heparin or acute clot • Do not ask for Prot C or S if pt has acute clot or is on coumadin • Molecular studies FV Leiden or Prothrombin gene mutation can be done anytime • If low plt or recent hospitalization think HIT

37. DVT/PE • Duration of anticoag (2008 ACCP guidelines) • Provoked • Provoking factor gone 3 months • Unprovoked (1st episode) • No less than 3 months, consider long term if no contraindications for AC • Unproked (2nd episode) • Lifelong

38. DVT/PE • 2.1.1. For patients with DVT secondary to a transient (reversible) risk factor, we recommend treatment with a VKA for 3 months over treatment for shorter periods (Grade 1A). • 2.1.2. For patients with unprovoked DVT, we recommend treatment with a VKA for at least 3 months (Grade 1A). We recommend that after 3 months of anticoagulant therapy, all patients with unprovoked DVT should be evaluated for the risk-benefit ratio of long-term therapy (Grade 1C). For patients with a first unprovoked VTE that is a proximal DVT, and in whom risk factors for bleeding are absent and for whom good anticoagulant monitoring is achievable, we recommend long-term treatment (Grade 1A). Values and preferences: This recommendation attaches a relatively high value to prevention of recurrent VTE and a lower value to the burden of long-term anticoagulant therapy. • For patients with a second episode of unprovoked VTE, we recommend long-term treatment (Grade 1A). For patients with a first isolated distal DVT that is unprovoked, we suggest that 3 months of anticoagulant therapy is sufficient rather than indefinite therapy (Grade 2B). • 2.1.3. For patients with DVT and cancer, we recommend LMWH for the first 3 to 6 months of long-term anticoagulant therapy (Grade 1A). For these patients, we recommend subsequent anticoagulant therapy with VKA or LMWH indefinitely or until the cancer is resolved (also, see Section 2.4) [Grade 1C]. • 2.1.4. In patients who receive long-term anticoagulant treatment, the risk-benefit ratio of continuing such treatment should be reassessed in the individual patient at periodic intervals (Grade 1C)

39. Filters • 1.13.1. For patients with DVT, we recommend against the routine use of a vena cava filter in addition to anticoagulants (Grade 1A). • 1.13.2. For patients with acute proximal DVT, if anticoagulant therapy is not possible because of the risk of bleeding, we recommend placement of an inferior vena cava (IVC) filter (Grade 1C). • 1.13.3. For patients with acute DVT who have an IVC filter inserted as an alternative to anticoagulation, we recommend that they should subsequently receive a conventional course of anticoagulant therapy if their risk of bleeding resolves (Grade 1C).

40. Porphyrias * * *