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Combat Hematology

Combat Hematology. Erik J. Rupard, MD MAJ, MC, USA. But First:. Why you, too, should join the Army Medical Corps. Army Medicine Advantages. You will not be burdened with excess cash. Army Medical Corps Motto: “Not EVERY doctor makes a lot of money”. AMEDD Advantages. 2. You get to:.

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Combat Hematology

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  1. Combat Hematology Erik J. Rupard, MD MAJ, MC, USA

  2. But First:

  3. Why you, too, should join the Army Medical Corps

  4. Army Medicine Advantages • You will not be burdened with excess cash. Army Medical Corps Motto: “Not EVERY doctor makes a lot of money”

  5. AMEDD Advantages 2. You get to: “Practice good medicine in bad places.”

  6. AMEDD = $$$ 3. You can make your family rich! OIF Deaths as of 01 JUL 2008: • Army 2971 • Navy 94 • Air Force 48 • Coast Guard 1 (source: iCasualties.org)

  7. CHALLENGES 4. Opportunities to excel • “Pee all that you can pee” • Army Physical Fitness Test • Grand Rounds • Good chance to practice your stand-up routine • Vince + Vance + YOU!

  8. Leadership Potential 5. If you join right now, there are many exciting opportunities for career growth.

  9. Why Cases? • Not a big fan of Power Point • Cases > lectures • Interactive learning > inactive learning • Allows for a discussion-based format • You hear from me • I hear from you • Maybe we both learn something

  10. How This Works • I’ll give you the basics of a case • All actual, recent cases • Some very recent • No patient identifiers (one notable exception) • We’ll go through the workup • Then: Actual diagnosis & discussion

  11. Case #1: Anemia • 23 year-old Hispanic female Army SPC • Presents to TMC • CC: “I am tired all the time” • SSG: “She has gotten very pale” • Decreased PT performance • A good tool to gauge function

  12. Treat and Test • Started on iron sulfate 325 PO TID w/ colace • But CANNOT assume iron deficiency • Must document via labs • Iron • Ferritin

  13. Iron-Deficiency • Very common • 11% of females 12-50 years-old* • Less than 2% of males in same age group • NOTE: incidence in elderly females = 7% • Harbinger of badness (if not menstrual) • 31 times risk of GI malignancy dx in 2 years • Ferritin < 10, LDH > 250 = 12% risk • LABS: microcytosis, high RDW, low ferritin • Anemia is a later finding • Elevated platelets even later

  14. Military Relevance?

  15. Military Relevance?

  16. Military Relevance • Iron deficiency is more common in female military members than in gen population • More military females are on diets • Greater exertion, greater muscle mass • Marching, walking, running increase hemolysis and hematuria

  17. Treatment • Give iron, start BID • Fe sulfate (325 mg = 65 mg elemental) • Fe fumarate (324 mg = 106 mg elemental) • Fumarate (a.k.a. “Hemocyte”) is better-tolerated • More iron per tablet • Not on CSH formulary • Take iron with acidic foods/drinks (soda, juice) • PPIs substantially reduce absorption

  18. What Happens • Reticulocytosis in 7 days • 2 g/dL increase in Hgb in 3 weeks • Equivalent of 2 units PRBCs • Quicker with IV iron • Platelets decline over 4-8 weeks • Eventual normalization, then overload SO: Have an endpoint. (Always!)

  19. Case #2: FLCs • 54 year-old African-American female • Referred for “refractory iron-deficiency anemia” • In fact, this was her fourth referral in the past 12 years • “Refractory to oral iron” • Prior colonoscopy/EGD = negative • Chart reviewed & labs ordered

  20. The CBC • WBC 7.2 • H/H: 11.6/36.3 • Review of chart • 10-year Hgb range = 11-13, no trend • Only one anemic value since Feb 1998 • Platelets 284 • MCV 70-74 • RBC 5.07

  21. Any guesses?

  22. Smear

  23. Iron Studies • Over past ten years, the right tests had been ordered many times • CBC, Iron, TIBC, Ferritin • 1996: Fe 98, TF 141, Sat 41%, Ferr 99 • 2006: Fe 71, TF 188, Sat 28%, Ferr 179

  24. Ferritin “50/50 Rule” Ferritin 50 = 50% chance of deficiency Log scale, so ferr 25 = 95%, 75 = 5%

  25. Hgb Studies • Sickle screen = negative (AA) • Hgb type found to be > 95% A1 SO: • Persistent microcytosis • Mild-to-no anemia • Normal basic Hgb electrophoresis

  26. Remember these?

  27. Thalassemia Review • Normal Hgb = tetramer of a-a-b-b • Confusing, but this a-a-b-b = “Hgb A” • Beta-thal = missing beta (some or all) • Minor = mostly still Hgb A • some a-a-d-d (Hgb A2), some a-a-g-g (Hgb F) • Major = NO Hgb A • High oxygen affinity • Hemolysis/fragile cells • Extramedullaryhematopoesis

  28. Alpha Thal • 4 alpha genes • Missing 1 = nl phenotype • Missing 2 = mild microcytosis • Missing 3 = similar to thal major • Missing 4 = incompatible with life • HgbBarts (g-g-g-g)

  29. Key Points About Alpha • Mild disease is NOT picked up on Hgb electrophoresis • Diagnosis can be made clinically • Microcytosis • No iron deficiency (often excess) • Correct Population • African, Asian, Mediterranean descent • COMMON = 30% of African-Americans

  30. How do you treat it? Resist the urge. (Which leads us to…)

  31. Rupard Rant #1 • Don’t check anything that you don’t have to • “Picking nose in public” • Especially true in theater • Pet peeve: cholesterol/lipids • Starting statin here is NOT benign (f/u?) • Patients do NOT follow normal diet/exercise pattern

  32. Case #3: ET Go Home • 34 y/o Marine SSG with Essential Thrombocythemia (ET) • h/o CAD with “strange” LAD lesion • Bypass LIMA 5/07 • Also HTN and HLD • Currently asymptomatic

  33. E.T. Case… • Eval by Hematologist prior to deployment • “Fit For Duty”  Al Asad • CBC • WBC 4.9, Hgb 16.4, Plts 1,032,000 • PCM here concerned about plt count

  34. Elevated Platelets • Clinically, not an issue for “normal people” unless plts > 1.5 million • Causes: iron deficiency, polycythemia vera, inflammation, splenectomy, and essential thrombocythemia

  35. What Is E.T.? • In short, it is leukemia of platelets… • …but we don’t call it that. • Diagnosis • Platelets > 600,000 in absence of other causes • Consistent bone marrow biopsy

  36. Who Gets Treated? Age > 60 or h/o bleeding or thrombosis or Platelets > 1,500,000

  37. Who Gets Treated? Age > 60 or h/o bleeding/thrombosis or Platelets > 1,500,000 Lacking these findings, ET patients have same risk of clot as general population.

  38. Treatment • Hydroxyurea (hydrea) • Alkylator = kills dividing cells (a.k.a. chemo) • Reduces plt count and risk of clot/bleed • Goal = less than 400,000 plts • Side effects: anemia, leukopenia, fatigue

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