ITP

• related: Hemeonc

• Patients with asymptomatic mild thrombocytopenia (platelets >30,000/µL without bleeding) can generally be observed without treatment.
• Corticosteroids are a first-line treatment option for patients with symptoms and/or a platelet count of <30,000/µL; the majority of adults respond within 1-2 weeks.
• Intravenous immunoglobulin can be cons

Anemia

• ineffective erythropoiesis, Hemeonc

Microcytic anemia

Thalassemia

Screening for anemia is routine at the first prenatal visit. Patients with thalassemia minor (ie, thalassemia trait) have mild **micr

Bleeding disorders overview

• related: Hemeonc
• tags: #hemeonc

---

• Intrinsic bleeding disorder
  • prolonged PTT
  • hemophilia A(8)/B: nl PT, bleeding time, plt count
    • replace with DDAVP and aminocaproic acid for hemophilia A
    • can also give factor 8
  • vWF: increased PTT and bleeding time
    • riscocetin test for diagnosis
    • DDAVP and am

Bleeding disorders

• related: Hemeonc

• ITP

Prolonged aPTT and normal PT (INR) suggest an intrinsic pathway defect.  Deficiencies of factor XII, prekallikrein, or high molecular weight kininogen all cause a prolonged aPTT without clinical bleeding.  Prolonged aPTT with bleeding can occur in congenital or acquired von Willebrand disease and isolated deficiencies of factors VIII, IX, a

DVT and PE

• related: Hemeonc
• tags: #hemeonc

---

It is unusual for an otherwise healthy 37-year-old to suddenly develop a DVT, especially in the absence of any recent provoking factors such as trauma, surgery, or a long plane trip. The sudden death of this patient's paternal uncle at a young age should raise a red flag that he may have an inherited hypercoagulable condition. The most common cause of inherited thrombophilia (accounting for approximately 50% of c

Medicine

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• Urology
• Neurology
• Pulmonology
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transfusion goals

• related: Hemeonc
• tags: #literature
• source: Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB

---

• transfuse rbc for goal of 7 for stable hospitalized patients or 8 for cardiac or surgical patients

TRICC and POCUS

• transfusion goal of 7 for stable patients in hospital
• transfusion goal of 8 or if symptoms for preexisting CV disease patie

Transfusion Medicine

• related: Hemeonc

---

• transfusion products
• transfusion goals
• transfusion reaction
• massive transfusion protocol

Transfusion Rate

Warfarin

• related: Hemeonc, INR goals

---

Warfarin is an anticoagulant commonly used in the treatment of atrial fibrillation and venous thromboembolism. Effects arise from the inhibition of vitamin K recycling, which reduces circulating levels of vitamin K-dependent clotting factors II, VII, IX, and X. The major risk of therapy is bleeding-associated complications, particularly intracranial hemorrhage.

Patients on warfa

heparin induced thrombocytopenia and thrombosis

• related: Hemeonc
• tags: #hemeonc

---

type 1 HITT

• within 2 days of initiating heparin
• transient, non pathologic
• Plt > 100k
• Do not stop heparin, plt will return to normal

type 2 HITT

• antibody against PF4 => activates Plt => plt cascades => thrombosis and thrombocytopenia
• risks
  • women
  • most often unfractionated heparin
  • CV

febrile neutropenia

• related: Hemeonc, notes

Neutropenic prophylaxis

• antiviral: acyclovir if HSV+
• antifungal
  • fluconazole if on cytarabine/venetoclax
  • posaconazole if on 7+3, cytarabine/daunorubicin/midaustaurin
• antibacterial
  • moxifloxacin inpatient
  • levofloxacin ambulatory

• maintain gram negative coverage until ANC resolves

![](https://photos.thisispiggy.com/fi

TTP

• related: Hemeonc

---

This patient likely has thrombotic thrombocytopenic purpura (TTP), which is characterized by the formation of small-vessel, platelet-rich thrombi due to severe deficiency of the von Willebrand factor–cleaving protein ADAMTS13.  TTP can be associated with pregnancy due to the formation of autoantibod

disseminated intravascular coagulation

• related: Hemeonc, DIC vs liver disease
• tags: #note

Common Causes

Common Causes

• sepsis: not that common
• most common: malignancy (APL), B cell malignancies
• pregnancy/delivery, amniotic fluid

Pathogenesis

• exposure to TF => thrombosis => clotting
• dysregulation of coagulation system: everything ramped up. More coagulation and fibrinolysis

Stage 1

• PT/PTT: normal/low
• microthrombi, schisctocytes
• A

leukostasis

• related: Hemeonc

Leukostasis

• blasts > 50 with symptoms

• 80 concerning

• 100 ppx leukopheresis

tumor lysis syndrome

• related: Hemeonc
• tags: #hemeonc

---

Tumor lysis syndrome (TLS) occurs when a large tumor burden undergoes rapid destruction with release of its intracellular contents into the bloodstream.  Resulting electrolyte and metabolic abnormalities can cause acute kidney injury (eg, calcium-phosphate precipitation in renal tubules), arrhythmias (eg, calcium-phosphate precipitation in the heart), seizures, and possible sudde

anemia lecture

• related: Hemeonc

---

• MCV

  • changes with age
  • 

• macrocytosis: defect in DNA synthesis

• microcytosis: defect in hemoglobin synthesis

IDA

• blood loss: GI work up, menopause
• increased requirements: pregnancy/lactation
• decreased dietary intake
• decreased absorption: celiac, gastric bypass

Treat

blood smear

• related: Hemeonc

---

Overview

• look in monolayer region, red cells not overlapping but almost touching

Terminology

• background: not significant
• trace: not totally confident real finding
• 1+ first step with confidence abnormal
• 4+

essential thrombocytosis

• related: Hemeonc

---

• questions to ask
  • splenomegaly
  • menstrual hx
  • hx of clots
  • family hx
• sx
  • 
• labs
  • iron profile
  • esr/crp
  • ldh
  • uric acid
  • JAK2: V617F, exon 12
  • CALR
  • MPL

Patients with ET are often asymptomatic but can develop vasomotor symptoms (eg, headaches, dizziness,

polycythemia vera

• related: Hemeonc, essential thrombocytosis

---

• erythrocytosis
• questions to ask
  • smoking history
  • hormonal therapy (testosterone increases Hgb)
  • OSA hx
  • renal/liver cancer
  • burning pain in hands/feet
  • itching
  • fatigue
• physical exam findings
  • facial plethora
  • red extremities
  • clubbing
  • splenomegaly
• labs
  • iron profile
  • LDL
  • uric acid
  • EPO

DIC vs liver disease

• related: Hemeonc
• tags: #note

---

• Check factor 8
• Produced by endothelial cells
• Increased in liver disease: released as liver cells are destroyed
• Decreased in DIC: activated protein C proleolyses factor 8

anticoagulation reversal

• related: Hemeonc
• tags: #hemeonc

---

Pradaxa (dabigatran)

Use Praxbind (idarucizumab) for Pradaxa reversal. Dialysis is alternative but could take too long and could have problem with vas cath insertion when bleeding.

Check PTT and thrombin time if available

Eliquis and Xarelto

Use Kcentra or FEIBA for reversal.

• FEIBA is 4 factor concentrates: 2, 7, 9, 10
• Kcentra has 2, 7, 9, 10 but also protein C and S but could take longer

massive transfusion protocol

• related: transfusion medicine, Hemeonc
• tags: #hemeonc

---

• Ratio 1:1:1:1: pRBC, FFP, plt, cryo

• hypocalcemia is common abnormality after massive transfusion

---

Literature Notes

• ibcc massive transfusion protocol

prevention of recurrent VTE in cancer patients

• related: Hemeonc
• tags: #hemeonc

---

Patients with cancer have a 4-7 fold increased risk of venous thromboembolism (VTE).  Long-term VTE treatment is different in cancer patients than patients without cancer.  Low molecular weight heparin (LMWH) is more effective than vitamin K antagonists (e.g., warfarin) in reducing the risk of recurrent VTE in cancer patients (while on therapy), and they do not signific

autoimmune hemolytic anemia

• related: Hemeonc
• tags: #hemeonc

---

This patient's presentation suggests autoimmune hemolytic anemia (AIHA), a complication in about 10% of patients with systemic lupus erythematosus (SLE).  AIHA is due to autoantibodies (warm agglutinins or IgG antibodies and cold agglutinins or IgM antibodies) destroying red blood c

supratherapeutic INR

• related: Hemeonc
• tags: #hemeonc

---

Patients on warfarin therapy are at risk for elevated INR due to drug interactions, vitamin K deficiency, and superimposed conditions (eg, diarrhea, fever, liver disease, heart failure).  Impaired cognition, depression, or low literacy can also lead to elevated INR due to incorrect warfarin

management of bone metastasis

• related: Hemeonc
• tags: #hemeonc

---

In patients with bone metastases, osteoclast-inhibiting agents such as denosumab and bisphosphonates significantly decrease the risk of **skeletal-related events** (SREs) (eg, fracture, skeletal instability/loss, spinal cord compression) and can delay symptom onset, fracture formation, need for irradiation, development of hypercalcemia,

Breast Cancer

• related: Hemeonc, breast nodule and mass
• tags: #hemeonc

---

Introduction

Breast cancer is the most common type of cancer in women in the United States, excluding skin cancers. In 2015, there were an estimated 231,840 new invasive breast cancer cases and 60,290 in situ cases diagnosed. The lifetime risk of developing invasive breast cancer is 12.4% (about 1 in 8) for U.S. women. There were an estimated 40,290 deaths from breast cancer in the

Cancer of Unknown Primary Site

• related: Hemeonc
• tags: #hemeonc

---

Introduction

Despite steady improvements in diagnostic and imaging techniques during the past decades, a reasonable evaluation will not identify the source of cancer in a small number (less than 5%) of all patients presenting with metastatic cancer. This heterogeneous group of patients is classified as having cancer of unknown primary (CUP). As diagnostic imaging continues to improve, the freq

Effects of Cancer Therapy and Survivorship

• related: Hemeonc
• tags: #hemeonc

---

Effects of Cancer Therapy

Hematologic Toxicity

The major toxicity of many traditional chemotherapeutic agents remains myelosuppression, leading to anemia, neutropenia, and thrombocytopenia.

Neutropenia and Fever

The risk of infection increases with the magnitude and the duration of neutropenia, which typically occurs 5 to 15 days after chemotherapy administration. Serio

Erythrocyte Disorders

• related: Hemeonc
• tags: #hemeonc

---

Approach to Anemia

Anemia is a pathologic state resulting in an insufficient number of erythrocytes to deliver oxygen to organs and tissues. Anemia can arise from blood loss, underproduction of erythrocytes, destruction of erythrocytes (hemolysis), or a combination of these factors. Patients with chronic anemia may be entirely asymptomatic or may experience symptoms of dyspnea, decreased exercise toler

Gastroenterological Malignancies

• related: Hemeonc
• tags: #hemeonc

---

Colorectal Cancer

Colorectal cancer (CRC) is the fourth most common cancer and the second leading cause of cancer death in North America, yet it is largely preventable through screening. CRC screening of average-risk patients is discussed in MKSAP 18 General Internal Medicine. ==Most colon cancers are adenocarci

Genitourinary Cancer

• related: Hemeonc
• tags: #hemeonc

---

Prostate Cancer

Epidemiology and Risk Factors

Adenocarcinoma of the prostate remains one of the most commonly diagnosed types of cancer among men in the United States, with an estimated lifetime risk of one in seven. Age is a very important risk factor; prostate cancer is rarely diagnosed before age 40 years, but after that point, the incidence increases significantly. Ethnicity is also an importan

Head and Neck Cancer

• related: Hemeonc
• tags: #hemeonc

---

Head and neck cancers include primary tumors of the oral cavity, oropharynx, nasopharynx, hypopharynx, larynx, paranasal sinuses, thyroid, and salivary glands. Squamous cell carcinoma is the most common form of head and neck cancer and is therefore the focus of this chapter. Thyroid cancer is discussed in [MKSAP 18 Endocrinology and Metabolism](https://mksap18.acponline.org/app/topics/en/mk18_b_en_s4/mk18_b

Hematologic Issues in Pregnancy

• related: Hemeonc
• tags: #hemeonc

---

Gestational Anemia

During pregnancy, an increase in plasma volume occurs that is greater than the increase in erythrocyte mass, resulting in a physiologic decrease in measured hemoglobin level, although it typically remains greater than 10.5 g/dL (105 g/L). If the hemoglobin level decreases further, additional evaluation of the anemia is warranted. Iron, vitamin B12, and folate levels should

Hematopoietic Stem Cells and Their Disorders

• related: Hemeonc
• tags: #hemeonc

---

Overview

Hematopoietic stem cells nest in the bone marrow and have the capacity to differentiate and self-renew. Hematopoietic stem cells are multipotent and can differentiate into progenitor cells; in turn, these produce leukocytes, erythrocytes, and platelets. This differentiation and proliferation to mature blood cells happens in an orderly manner called hematopoiesis. Hematop

Iron Overload Syndromes

• related: Hemeonc
• tags: #hemeonc

---

Primary/Hereditary Hemochromatosis

Related Question

• Question 26

Hereditary hemochromatosis (HH) is the most common inherited genetic disorder in Whites, with a prevalence of 1 in 250 persons of northern European descent. Approximately 85% to 90% of patients with HH are homozygous for the C282Y mutation in the HFE gene; the remaining patients are typically compound heterozygotes for C282Y a

Issues in Oncology

• related: Hemeonc
• tags: #hemeonc

---

Introduction

Technological advances are changing the field of medical oncology at a rapid rate. The successful incorporation of immune checkpoint inhibitors and other immunologic strategies to facilitate activation of the patient's own immune system as part of the standard treatment of many malignancies has been a major advance. Other changes include expanded routine use of molecular profiling in several

Lung Cancer

• related: Hemeonc
• tags: #hemeonc

---

This section will focus on treatment and follow-up of patients with lung cancer. See MKSAP 18 Pulmonary and Critical Care Medicine for discussion of epidemiology, screening, clinical manifestations, diagnosis, and staging of patients with lung cancer. Initial biopsy can distinguish tumors as either non–small cell lung cancer (NSCLC) or small

Lymphoid Malignancies

• related: Hemeonc
• tags: #hemeonc

---

Epidemiology and Risk Factors

The American Cancer Society estimates that in 2018 83,180 new cases of lymphoma will be diagnosed in the United States. The lifetime risk of developing non-Hodgkin lymphoma is 2.1%, whereas the lifetime risk of developing Hodgkin lymphoma is considerably less. Although incidence has only slightly declined recently, death rates have decreased significantly owing to improvem

MKSAP Bleeding Disorders

• related: Hemeonc
• tags: #hemeonc

---

Normal Hemostasis

Hemostasis is the process by which bleeding is controlled through a complex network of prothrombotic and fibrinolytic activity. Clot generation occurs on phospholipid membranes through the activation of procoagulant factors (Figure 17). Traditionally, the process was described as a waterfall coagulation cascad

MKSAP Cervical Cancer

• related: Hemeonc
• tags: #hemeonc

---

Epidemiology and Risk Factors

In 2018, there will be an estimated 13,240 new patients diagnosed with invasive cervical cancer and 4170 deaths from cervical cancer in the United States. The mean age of diagnosis in the United States is 48 years. During the last 30 years, cervical cancer incidence and deaths in developed countries have decreased by more than 50%, primarily because of screening and preven

MKSAP Transfusion Medicine

• related: Hemeonc
• tags: #hemeonc

---

Clinical trials supporting the benefits of a more cautious transfusion strategy have dramatically changed transfusion practice. For elective transfusions, ABO and Rh matching based on a properly labeled blood specimen remains the cornerstone of safe transfusion. Approximately 5% to 10% of hospitalized patients have evidence of erythrocyte alloimmunization from previous transfusions, pregnancy, or orga

Melanoma

• related: Hemeonc
• tags: #hemeonc

---

Melanoma has been steadily increasing in incidence worldwide, with risk related to sun exposure. Most melanomas begin in and present with cutaneous disease, but they can also begin in mucosal sites. About half arise in preexisting nevi, but many begin in apparently normal skin. Melanoma can also present in nodal or visceral sites without a known cutaneous or mucosal primary. About 10% of patients with melanoma have a f

Multiple Myeloma and Related Disorders

• related: Hemeonc
• tags: #hemeonc

---

Overview

B-cell maturation to plasma cells involves early antigen-independent and antigen-dependent phases. When humoral immunity is stimulated by an infection or inflammation, multiple clones of plasma cells are expanded. These plasma cell clones can produce immunoglobulins of different classes and specificity, giving the characteristic polyclonal spike seen on protein electrophoresis

Oncologic Urgencies and Emergencies

• related: Hemeonc
• tags: #hemeonc

---

Structural Urgencies and Emergencies

Superior Vena Cava Syndrome

Obstruction of the superior vena cava (SVC), or SVC syndrome, occurs in approximately 15,000 persons in the United States each year. Most cases are caused by malignancies with large mediastinal masses. Patients typically present with edema of the head, neck, and arms, often with cyanosis, plethora, and distended cutaneo

Ovarian Cancer

• related: Hemeonc
• tags: #hemeonc

---

Epidemiology and Risk Factors

Related Question

• Question 86

Ovarian cancer, the leading cause of gynecologic cancer deaths, will be newly diagnosed in approximately 22,000 women in 2016 in the United States, with an estimated 14,000 deaths. This chapter will focus on the 95% of ovarian cancers that are of epithelial origin.

Risk factors for ovarian epithelial cancer include inheritance of ovarian can

Platelet Disorders

• related: Hemeonc
• tags: #hemeonc

---

Normal Platelet Physiology

Platelets are cell fragments released from megakaryocytes that circulate in an inactive state in the blood for 8 to 10 days. One third of the platelets are sequestered in the spleen and released back into the circulation in response to epinephrine.

Platelet activation, the first step in hemostasis, occurs in a three-stage process. Platelets adhere to exposed subendothelial surf

Thrombotic Disorders

• related: Hemeonc
• tags: #hemeonc

---

The burden of venous thromboembolic disease continues to increase despite increased awareness of risk factors and prevention options. The incidence of a first episode of venous thromboembolism (VTE) is approximately 1 to 2 per 1000 person/years.

VTE most commonly manifests as lower extremity deep venous thrombosis (DVT) or pulmonary embolism (PE). Many nosocomial VTEs are preventable, although thromboproph

breast nodule and mass

• related: Hemeonc, Breast Cancer
• tags: #hemeonc

---

A palpable breast mass is a common presenting symptom of breast cancer.  Breast masses that are firm, immobile, irregularly shaped, and accompanied by lymphadenopathy, nipple discharge, or skin changes are concerning for malignancy.  However, history and physical examination are not sufficient to diagnose or exclude malignancy, and further evaluation with imaging is required.

In **wome

metastatic colon cancer to liver

• related: GI, Hemeonc
• tags: #hemeonc

---

Approximately 20% of patients with colorectal cancer have metastatic disease at diagnosis.  Common sites include the liver, lung, peritoneum, and lymph nodes.  Most cases are incurable, but patients with liver-isolated colorectal cancer can sometimes be cured with surgical resection.  Surgery can generally

anterior mediastinal mass

• related: Hemeonc
• tags: #hemeonc

---

The differential diagnosis for an anterior mediastinal mass includes the "4 T's":

• thymoma
• teratoma
• thyroid neoplasm
• terrible lymphoma

Within the category of teratoma, one must also include other germ cell tumors. Teratomas can often be distinguished from other germ cell tumors on imaging by the presence of fat or calcium, particularly if in the form of a tooth. Serum hormone levels

myelofibrosis

• related: Hemeonc
• tags: #hemeonc

---

This patient has normocytic anemia, massive splenomegaly, and teardrop cells on peripheral smear.  These findings are consistent with primary myelofibrosis (PMF).  Primary myelofibrosis is a chronic myeloproliferative disorder characterized by an overproduction of megakaryocytes and bone marrow stromal cells, which release fibrosis-promoting cy

comparing different anticoagulants, warfarin, coumadin, doacs

• related: Hemeonc
• tags: #hemeonc

---

Systemic thromboembolism is a major cause of long-term morbidity in patients with atrial fibrillation.  Treatment with warfarin or target-specific oral anticoagulants (TSOACs: dabigatran, rivaroxaban, apixaban, edoxaban) has been shown to significantly reduce the risk of embolization in pa

long term complications of non hodgkin lymphoma

• related: Hemeonc
• tags: #hemeonc

---

Non-Hodgkin lymphoma (NHL) survivors are at increased risk for many long-term complications such as second malignancies, cardiovascular disease, endocrine problems, and neuro-psychiatric complications.  As the risk of NHL relapse decreases after five years of treatment, long-term care of these patients is incre

perioperative management of von willebrand disease vwd vwf

• related: Hemeonc, Perioperative
• tags: #hemeonc

---

Von Willebrand disease (VWD) is the most common inherited bleeding disorder.  Type 1 VWD accounts for 75% of cases and is marked by a quantitive deficiency of von Willebrand factor (VWF), leading to low VWF antigen, VWF activity, and factor VIII levels.  Patients with b

treat solitary lung brain mets with surgical resection

• related: Hemeonc
• tags: #hemeonc

---

Nearly 40% of patients with systemic cancer develop brain metastases, usually through hematogenous spread.  Imaging features suggesting metastatic disease include circumscribed margins, location at the gray-white matter junction, patterns of vasogenic edema, and multiple lesions.  The most common und

acquired coagulation factor inhibitors

• related: Hemeonc
• tags: #hemeonc

---

The coagulation studies reveal a normal PT and a prolonged aPTT, which is indicative of an intrinsic pathway disorder and is the typical pattern seen in patients with hemophilia A and B, von Willebrand disease, and certain acquired disorders. Becaus

acute bleeding classifications

• related: Hemeonc
• tags: #hemeonc

---

Use heart rate and urine output as initial assessment of volume loss. Patients with tachycardia and decreased urine output have at least 30% blood loss and are labelled as Class III or IV acute hemorrhage. They may have confusion and decreased pulse pressure. Consider replace with blood products besides volume expansion.

• [[transfusing chronical anemic patients to hemoglobin goal can cause worse

anticoagulation agents

• related: coagulation cascade, Hemeonc
• tags: #hemeonc

---

• Warfarin is a Vitamin K antagonist. Vitamin K is required for Factor 2, 7, 9, 10, C, S
• DOACS are direct oral anticoagulants. They are divided into 10a inhibitors and IIa inhibitors
• 10a inhibitors:
  • Apixaban (Eliquis)
  • Rivaroxaban (Xarelto)
• 2a inhibitors:
  • dabigatran (Pradaxa)
  • argatroban

coagulation cascade

• related: Hemeonc, anticoagulation agents
• tags: #hemeonc

---

Coagulation

• Coagulation happens with
  • endothelin release from site of damage leading to vasoconstriction
  • endothelial damage leads to platelet activation leading to thrombus
  • endothelial damage leads to coagulation factor activation. Fibrin is formed leading to thrombus

Cascade

Coagulation cascade has

hypocalcemia is common abnormality after massive transfusion

• related: Hemeonc, massive transfusion protocol
• tags: #hemeonc

---

• blood products have citrate preservative that binds to endogenous calcium after transfusion, leading to hypocalcemia
• hypocalcemia can cause coagulopathy
• don't wait for hypocalcemia on labs. Aim for mildly elevated calcium levels in massive transfusion

---

use mixing studies to differentiate deficiency vs inhibitors

• related: Hemeonc
• tags: #hemeonc

---

Prolonged aPTT and normal PT (INR) suggest an intrinsic pathway defect.  Deficiencies of factor XII, prekallikrein, or high molecular weight kininogen all cause a prolonged aPTT without clinical bleeding.  Prolonged aPTT with bleeding can occur in congenital or acquired von Willebrand disease and i

ibcc anemia, bleeding, transfusion

• related: Hemeonc, transfusion medicine
• tags: #literature
• source: https://emcrit.org/ibcc/transfusion, https://emcrit.org/ibcc/gib/

---

Nonbleeding

• anemia panel is not useful in acute ICU hemoglobin drop
• Iron supplementation not helpful in ICU anemia
• transfusion can cause worsening hyperkalemia
• transfuse dialysis patients during dialysis

GI bleed

• normal Hgb with unstable hemodynamics more worrisome than a

transfuse rbc for goal of 7 for stable hospitalized patients or 8 for cardiac or surgical patients

• related: Hemeonc, transfusion goals
• tags: #permanent

---

For stable, nonbleeding, hospitalized patients, transfusion goal should be 7. For stable, nonbleeding, hospitalized patients who have preexisting coronary artery disease or are undergoing surgery, transfusion goal should be 8 or if patient is symptomatic (chest pain, tachycardia, hypotension). No transfusi

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