Hematology

Question 1

Causes of Neutrophilia

Answer 1

• CLL
• Smoking
• Steroid
• Lithium

Question 2

Indication of treatment of Polycythemia Vera

Answer 2

With additional risk factors including
- Age older than 60 years or
- h/o thromboembolic event

Should receive cytoeductive therapy with hydroxyurea or interferon alpha. PLUS ASPIRIN.
(Ruxolitinib for intolerant to first line agent or resistant PV)

Question 3

Chemotherapy induced neutropenia typically occurs within…

Answer 3

5 to 15 days following chemotherapy.

Question 4

Prophylactic Indication of G-CSF

Answer 4

• high risk patients (undergoing allogeneic stem cell transplantation or receiving induction chemo for acute leukemia) of neutropenia
• as secondary prophylaxis in patient with previous episode of febrile neutropenia

Usually given on day 2 of chemotherapy.

Question 5

Survivors of pediatric leukemia (typically acute lymphoblastic leukemia) are at increased risk of developing

Answer 5

• metabolic syndrome
• so screening for dyslipidemia, diabetes mellitus, and hypertension is recommended.

Question 6

Key Points

Answer 6

The dilute Russell viper venom time is an assay used to confirm the presence of a lupus anticoagulant (LAC), which might be a diagnostic consideration if the prolonged aPTT fails to correct following a one-to-one mixing study.

Question 7

What is the diagnosis?
- Chronic Hypochromic Microcytic Anemia
- Target cells of peripheral blood smear
- Normal hemoglobin electrophoresis

Answer 7

Alpha Thalessemia Trait.

“Silent carrier” do not have anemia.

Question 8

Key Point

Answer 8

Patients with β-thalassemia have chronic microcytic anemia, target cells on the peripheral blood smear, a reduced hemoglobin A level, and elevated levels of hemoglobin F and hemoglobin A2 on hemoglobin electrophoresis.

Question 9

Key Points

Answer 9

The hallmark of chronic myeloid leukemia is the Philadelphia chromosome, a reciprocal translocation of the ABL gene on chromosome 9 to the BCR gene on chromosome 22, designated as t(9;22).

A tyrosine kinase inhibitor such as imatinib is considered first-line treatment for patients with chronic myeloid leukemia diagnosed in the chronic phase (<10% blasts in the bone marrow).

Question 10

Indication of Steroid in ITP

Answer 10

• Platelet count less than 30K who are asymptomatic or
• who have mucocutaneous bleeding

course (<6 weeks) of prednisone or dexamethasone. The response to intravenous immune globulin is faster and may be indicated in patients with more severe thrombocytopenia and life-threatening bleeding.

Question 11

Indication of platelet transfusion in ITP

Answer 11

If only patient is bleeding

Question 12

Treatment of metastatic Non Small Cell Lung cancer with ALK translocation

Answer 12

Alectinib

Question 13

Patient taking aromatase inhibitor without active cancer

Answer 13

• should take calcium and vitamin D
• should get annual DEXA scan
• confirmed Osteoporosis>start Alendronate

But if patient is on active anti-cancer therapy, patient should be started on Alendronate/bisphosphonate irrespective of osteoporosis

Question 14

Key Point

Answer 14

CLL without significant symptoms, bulky adenopathy or cytopenias shouldn’t be initiated on treatment.

Question 15

Gastroesophageal tumor should be evaluated for expression of

Answer 15

Human Growth Factor 2 (HER2)

Question 16

Melanoma should be evaluated for expression of

Answer 16

BRAF mutation

Question 17

Key Point

Answer 17

• Elevated CEA level indicates worse prognosis for patient at any stage of colon cancer.
• Rising CEA level during surveillance period after resection indicates recurrence.

Question 18

Indication of Lung cancer screening

Answer 18

• 50-80 years age
• 20 Pack year
• quit less than 15 years ago

With Low dose Chest CT annually.

Question 19

Typical Findings in DIC

Answer 19

• thrombocytopenia
• prolonged coagulation measures
• hypofibrinogenemia
• elevated d dimer level

Question 20

Key Point

Answer 20

For patients with pulmonary embolism (PE) with a low risk for complications, the American Society of Hematology guideline suggests offering home treatment over hospital treatment.

Can use Pulmonary Embolism Severity Index, to predict outcome but not replace clinical judgement.

Question 21

Indication for platelet transfusion

Answer 21

• patients with platelet counts less than 50,000/μL (50 × 109/L) before undergoing invasive procedures or general surgery with a significant risk of bleeding.

Question 22

Key Points of Drug induced Neutropenia

Answer 22

Drug-induced neutropenia results from
- impairment of normal granulopoiesis in the bone marrow or
- through a drug-dependent, antibody-mediated immune destruction of circulating neutrophils.

The thionamides propylthiouracil and methimazole are among the drugs known to cause agranulocytosis; although the overall prevalence is low (around 0.5%), the risk is higher compared with other drug classes.
- Agranulocytosis is more likely to occur within the first 3 months of drug initiation
- more common in women
- appears to be dose related with methimazole.
- The ANC should recover within 1 to 3 weeks after discontinuing the medication.

Question 23

Key Points

Answer 23

Never test for protein c, protein s and Antithrombin II (Hypercoagulable workup0 during inpatient settings.

Question 24

Patient with Heparin Induced thrombocytopenia can be switched to

Answer 24

• If renal function is normal, either Apixaban or Rivaroxaban
• Fondaparinux or Argatroban can also be considered.

Question 25

Key Points about Aplastic anemia

Answer 25

Allogeneic hematopoietic stem cell transplantation is the preferred treatment for aplastic anemia in younger patients who have an HLA-matched stem cell donor. In patients older than 50 years and in younger patients without a suitable stem cell donor, aplastic anemia is treated by immunosuppression with antithymocyte globulin, cyclosporine, and prednisone.

Question 26

Key Points about Warfarin and INR

Answer 26

- Patients taking warfarin with a supratherapeutic INR less than 10 and no signs of bleeding, warfarin should be withheld until the INR returns to the therapeutic range - For INR elevation greater than 10 without bleeding, vitamin K is recommended in addition to withholding warfarin - If the INR is elevated and life-threatening bleeding is present, then warfarin is withheld, and vitamin K and a prothrombin complex concentrate should be administered.

Question 27

Agent of choice for warfarin reversal

Answer 27

4-factor PCC is the preferred agent for warfarin reversal when a reversal agent is necessary. Fresh frozen plasma (FFP) is not the preferred agent when treatment of life-threatening bleeding is necessary for a patient with a supratherapeutic INR. 4-Factor PCC has been found to be noninferior to FFP in the treatment of life-threatening bleeding. Additionally, 4-factor PCC has a faster infusion time, more rapid reversal of INR, and lower risk of volume overload.

Question 28

Key Points about Anemia of Kidney disease.

Answer 28

- normochromic and hypoproliferative and typically has normal erythrocyte morphology on peripheral blood smear. (Echinocytes can be seen sometimes) The anemia of kidney disease is associated with a low or inappropriately low-normal erythropoietin level

Question 29

"... score" is calculated to determine use of anticoagulants in cancer patients in outpatient.

Answer 29

- Khorana Score In the absence of contraindications, outpatients with cancer at high risk of VTE (Khorana score of 2 or higher before starting a new systemic chemotherapy regimen) may be offered thromboprophylaxis with apixaban, rivaroxaban, or low-molecular-weight heparin.

Question 30

Key Points

Answer 30

If patient has isolated thrombocytopenia without other symptoms; think of immune thrombocytopenia. Check for: - HIV - HCV - H pylori (test if patient from endemic region) - Patients with HIV infection may have ITP independent of HIV viral load or CD4 cell count and may be otherwise asymptomatic.

Question 31

Reversal of Apixaban, Rivaroxaban, and Edoxaban

Answer 31

Andexanet alfa is a recombinant modified factor Xa that competes for binding to factor X with the factor Xa inhibitors

Question 32

Reversal of Dabigatran

Answer 32

Idarucizumab is safe and effective in reversing the anticoagulant effects of dabigatran. - if not able to get Idarucizumab, HD is an option (take 4 hours)

Question 33

MCV greater than 110-115

Answer 33

- folic acid and B12 deficiency - hydroxyurea - antiretrovirals HIV

Question 34

Score used to r/o PE

Answer 34

Pulmonary Embolism Rule-Out Criteria - Age <50 y, Initial heart rate <100 beats/min, Initial oxygen saturation >94% on room air, No unilateral leg swelling, No hemoptysis, No surgery or trauma within 4 weeks, No history of venous thromboembolism, No estrogen use. A meta-analysis of 12 studies showed that if the PERC is used, only 0.3% of PEs would be missed and 22% of D-dimer testing would have been safely avoided.

Question 35

Target hemoglobin before surgery sickle cell disease, particularly hemoglobin SS disease

Answer 35

10 g/dL SDD particulary hb SS disease, benefit from preoperative simple transfusion to achieve a hemoglobin level of 10 g/dL (100 g/L).

Question 36

Treatment of thrombotic thrombocytopenia purpura:

Answer 36

Plasma exchange, glucocorticoids, and rituximab. Do not choose plasmapheresis, plasma should be exchanged! ; Performing plasmapheresis with non-plasma replacement, such as saline and albumin, will remove the autoantibody but does not correct the ADAMTS13 deficiency. Plasma exchange and immunosuppressive therapy are crucial to remove the autoantibody, replace the deficient ADAMTS13, and prevent the formation of new autoantibody.

Question 37

Indication of treatment of hemochromatosis

Answer 37

The 2019 guideline from the American College of Gastroenterology (ACG) recommends treatment in patients with - homozygous C282Y mutations with - serum ferritin greater than 300 ng/mL (300 μg/L) in men and greater than 200 ng/mL (200 μg/L) in women - transferrin saturation of 45% or more. Other sources recommend observation for serum ferritin levels less than 500 ng/mL (500 μg/L) regardless of genotype. If Heterozygous- no need to treat or monitor

Question 38

Treatment is indicated for Superficial Vein Thrombosis

Answer 38

- thrombus is 5 cm or greater in length or - is close to the deep venous system or - if other thrombophilic risk factors are present. Total Duration is 6 weeks. If non met>f/u in 1 week>repeat Duplex.

Question 39

Key Points

Answer 39

Erythropoietin is important in the treatment of the anemia of chronic kidney disease (CKD) and is often needed in patients with end-stage kidney disease receiving dialysis. Guidelines recommend that erythropoietin-stimulating agents be withheld in patients with CKD not requiring dialysis who have a hemoglobin level greater than 10 g/dL (100 g/L).

Question 40

Indication of starting Chelation therapy in thalassemia major.

Answer 40

- serum ferritin level exceeds 1000 ng/mL (1000 μg/L) - after approximately 15 to 20 units of blood have been transfused, or - with evidence of organ deposition (>3 mg of iron per gram dry weight in the liver or cardiac T2* <20 milliseconds on MRI).

Question 41

Anticoagulation of choice for APLS

Answer 41

LMWH followed by Warfarin.

Question 42

Key Points

Answer 42

In patients taking dual antiplatelet therapy following coronary revascularization with significant hemorrhage, the best strategy is to discontinue the P2Y12 receptor (Plavix, Clopidogrel) antagonist and continue aspirin.

Question 43

Key Points

Answer 43

The myelodysplastic syndromes are clonal stem cell disorders with ineffective hematopoiesis leading to dysplastic, hypercellular bone marrow and peripheral blood cytopenias. Patients with the 5q− cytogenetic abnormality who are transfusion dependent can be treated with lenalidomide to decrease transfusion needs.