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distinguished between the mantle zone, light zone, and dark zone
Once plasma cells become activated and produce memory B-cells and plasma cells they travel back to the
bone marrow
Remember plasma cells make many immunoglobulins and more light chains (kappa and lambda) then heavy
chains so in multiple myeloma you have many, they are ineffective, MONOCLONAL chains.
Mott cells (pockets of immunloglobulins push out nuclear contents) and Flame cells (IgA myeloma) have
been associated with multiple myeloma
Picture of cast nephropathy from light chain deposition
o
Picture of Ig Deposition in the glomerulus lowering glomerular function which contribute to kidney damage
and resultant anemia
o
AL amyloidosis can occur to form BETA PLEATED SHEETS can occur anywhere
MGUS vs smoldering myeloma
o Smoldering myeloma
Asymptomatic myeloma
Serum M protein > 30 g/L or urinary M protein > 500 and clonal plasma cell percentage 10-
60%, no CRAB symptoms
o MGUS
Serum M protein is < 30g/L and clonal bone marrow cells < 10% no CRAB symptoms
Plasmacytoma
o Single localized tumor of monoclonal plasma cells with no features of multiple myeloma (solitary
plasmacytoma of bone or exramedullary)
Multiple myeloma can develop into a plasma cell leukemia in 1% of patients.
Waldenstrom’s macroglobulinemia comes from MEMORY B CELLS rather than plasma cells and that is
why they have IgM instead of IgG/IgA as in multiple myeloma
Myelodysplastic/Myeloproliferative Disorders
Hematopoietic
Stem Cells
Myeloid
Neoplasms MDS
MPN
MW11-14
o
Note FISH analysis shows combination of colors on one chromosome in 9,22 translocation
o Remember the myelocyte bulge is an important diagnostic clue here
o
o
o Note the progressions of myeloblast to promyelocyte into myelocyte, and then meta myelocyte
(indented nucleus), bands (which make her dance), and then segmented granulocytes (eosinophil
showed). In CML all of these are increased, especially myelocyte (myelocyte bulge)
CSF3R is a common mutation that is highly prevalent in chronic neutrophilic leukemia
Polycythemia Vera
o Patients have a ton of RBCs but also a lot of platelets
Essential Thrombocythemia
o Localized adjacent to sinuses
Myelodysplastic Syndromes
o You have pancytopenia, higher blast percentage <20 vs <10 in myeloproliferative diseases,
ineffective hematopoiesis
o What is it?
Stem-cell disorders involving ineffective hematopoiesis defects in cell maturation of
nonlymphoid lineages.
Caused by de novo mutations (50% such as 5q deletion or –Y deletion meaning men are
more likely to have it as they age) or environmental exposures such as radiation, benzene or
chemotherapy (therapy related is 90% and also due to the 5q or 7q deletion)
Huge difference is basically that myelodysplastic is a bunch of immature blast cells, whereas
myeloproliferative is an excessive production of usually one or more mature cells (ET
platelets) (CML myelocytes, basophils)
o A major anomaly associated with this condition is the Pseudo-pelger-huet anomaly neutrophils
have bilobed or “duet” nuclei and are usually seen after chemotherapy
o
o Many treatments exist, one in which she highlighted is DNA methyltransferase inhibitors (5-
azzacytidine)
Hematopoietic
Stem Cell
Acute
Myeloproliferative Myelodysplastic
Myeloid
Neoplasm Syndromes
Leukemia
o
o Important to remember both can progress to AML
Transfusions – Good Madam Coberly
Blood Bank Tests
o Type and Screen
Patients blood is forward/reverse blood typed
Antibody screen is performed
New patient sample must be collected and retested every 3 days
o Crossmatching
Basically you have packed RBC’s to set aside for future use by your patient with a
confirmatory type and screen
o Transfusion
Forward typing
o Patient with B blood has B antigen on their surface so when you had B antibodies there will be
clumping
Reverse typing
o Patient with B blood has A antibodies floating in serum. So when you add A blood, there should be
clumping in that test tube.
o
Antibody Screen
o Purpose is to screen for ABO antibodies (usually IgG) in the patient’s plasma
o Patient’s plasma is added to RBCs with known antigen phenotypes INDIRECT COOMBS!!
o Requires incubation so it takes longer
What’s in a Bag of Blood?
o RBC: 200-350 mL
o Plasma: <50 mL
o Iron: 200-250 mg
o For every unit of transfused blood we expect a Hb increase of 1g/dL and a hematocrit increase of 3%
A notable adverse event
o HYPOCALCEMIA!!!
o Blood is often anticoagulated with sodium citrate and citric acid and thus oftentimes blood
transfusions are accompanied by a large dose of citrate
o Citrate binds to free calcium leading to hypocalcemia
Platelets
o Psoralen drug is activated by UV light inactivating most bacteria, viruses, and WBCs in the bag
o Reduced incidence of transfusion reactions
o CAN BE GIVEN TO ANY BLOOD TYPE!
o Remember to not give to patients ITP or TTP
o Uremic platelet dysfunction remember leads to increased bleeding time, but no change in platelet
count or PT/PTT would NOT help
Plasma and Cryoprecipitate
o Cryo is usually only ever used for a fibrinogen deficiency or sometimes a Hemophilia A
o Perform transfusions right before planned procedures as Factor 7 has a short half life
Acute coronary syndrome
o Unstable angina troponins are NEGATIVE
o NSTEMI Positive troponins
Acute management O2, nitro, BB, ACEi, antiplatelet/antithrombotic therapy
(aspirin+clopidogrel (esp for patients who are allergic to aspirin)
o STEMI Troponins + ST elevations
The concept of Diversity of Lesions is UWORLD material
o A stenotic lesion has a thick cap, fibrotic, and there is less compensatory enlargement
o A nonstenotic lesion has a a lipid rich, thin cap, and there is compensatory enlargement
TIMI risk score calculates 30 day mortality after a MI, also GRACE score
CCS Classification (similar in terms of symptoms and severity to NYHA for CHF)
o Class I Strenuous activity causes problems
o Class II Slight limitation of ordinary activity (walking or climbing hills rapidly)
o Class III Great limitation of physical activity
o Class IV Can’t really to any physical activity
Co-morbidities
o HTN + dyslipidemia are the 2 major ones
o Pts often have peripheral pulses, valvular disease, HTN, lung disease, S3, S4
You can either perform a stress test or a noninvasive stress test (Adenosine PET being the highest
sensitivity and specificity)
Treatment includes PCI, fibrinolytics, CABG
COURAGE trial showed that death from MI, any cause of death, hospitalization for ACS, and rate of
acute MI was not changed significant with PCI vs medical therapy group
PCI is preferred over lysis due to lower rates of reinfarction, hemorrhagic stroke, and total stroke
Hypertension – Bostick
We care about HTN because CV mortality doubles with each 20 mmhG SBP or 10 mmhg DBP
increment (115/75 135/85)
End organ damage can occur to the
o heart leading to LVH, MI, HF
o PAD
o Brain TIA, dementia
o CKD, retinopathy
Pathophysiology of HTN
o Disorder of sodium metabolism leads to increased EC fluid volume
o Imbalance of RAAS system
o Endothelial dysfunction
o Sympathetic overactivity
o Mosaic theory
CAD, Stroke, PAD, CF go way down with proper BP control (Framingham heart study)
Basic testing you want to get when a patient has high BP Fasting Blood Glucose, Lipid profile, serum
creatinine with eGFR, serum sodium, potassium
Although many more Americans now qualify as hypertensive under the new JNC7 guidelines, only a
fraction require additional pharmacologic therapy
Use ACSVD Risk calculator to determine their lifetime complication of developing a cardiac event
In a young female patient with sudden change in BP, suspect a secondary HTN cause (RAS,
fibromuscular dyplasia etc)
We often give chlorthalidone a long acting HCTZ medication as a baseline treatment for HTN
Difference between MASKED HTN and WHITE COAT HTN
o Masked coat HTN BP is fine in clinic, but elevated at home checks
o White coat HTN BP is fine at home, but elevated in clinic
In a patient with stage II HTN 2 medications are needed, but stage I HTN start one and then adjust
In African Americans CCB + Thiazide diuretics (also more likely to require 2 meds)
o Beta blockers are not really recommended unless they have had an MI or you want to help
angina symptoms
o If he has kidney issues consider an ACEi or ARB
Hemodynamics - Aggarwal
Swan-Ganz Catheter
o 1cc of air is injected into the catheter and inflate the balloon which takes the free air to the left
atrium
o 10 cc of saline can be injected to determine temperature changes
Hemodynamics in AMI
Normal hemodynamics Pulmonary Congestion
PCWP <18 PCWP >25
CI >2.2 CI >2.2
o
ACE inhibitors are usually first line for mortality benefit
Sacubitril neprolysin inhibitor (BNP degradation inhibitor) + ARB
Hyperlipidemia
Evolocumab statin + PCSK9 inhibitor is even better then just a stain in reducing LDL cholesterol
Any statin is better than none and more potent is better than less potent
Statins cause myalgias and increase risk for type 2 DM, while decreasing exercise tolerance
Cholesterol Synthesis
o Important part of cell membranes and precursor to hormones, vitamin D, and bile acids
o Esterified by LCAT allows it to be stored in micelles so it can be transported
o
Lipids are transported via apolipoproteins combinations form HDL, IDL, LDL, VLDL
o
Pancreatic lipase degrades dietary TG in the lumen of the small intestine
o FFA enter enterocytes, re-esterify, and that transported as chylomicrons
Lipoprotein lipase is a vascular endothelium that degrades TG from chylomicrons so that their
degradation products can be absorbed remainder is transported to liver
Hormone sensitive lipase degrades stored TG
Hepatic TG lipase converts IDLs into LDLs
Lipid Lowering Agents
o HMG-CoA reductase inhibitors (lovostatin)
Greatly decrease LDL, slightly increase HDL, and decrease TG
MOA: Inhibit conversion of HMG-CoA reductase to mevalonate
Side effects: Hepatotoxicity, myopathy
o Bile acid resins (cholestyramine, colestipol)
Decrease LDL, slightly increase HDL and TG
MOA: Prevent intestinal reabsorption of bile acids, liver must now use cholesterol to
make more
GI upset, decreased absorption of other drugs and fat soluble vitamins
o Ezetimibe
Prevents cholesterol absorption at brush border can lead to diarrhea
o Fibrates (gemfibrozil, bezafibrate)
Decrease LDL, increase HDL, and greatly decreased TG
MOA: Upregulate LDL increase TG clearance
Activates PPAR-a to induce HDL synthesis
Side effects: Myopathy, cholesterol gallstones (inhibits cholesterol 7a hydroxylase)
o Niacin (vitamin B3)
Decreases LDL, increases HDL, decreases TG
MOA: Inhibits lipolysis (hormone sensitive lipase) in adipose tissue, reduces hepatic
VLDL synthesis
Side effects: Red, flushed face, decreased by NSAIDS or long-term use, hyperglycemia,
hyperuricemia
o PCSK9 inhibitors (alirocumab, evolocumab)
Greatly decrease LDL
Inactivate LDL receptor degradation, increasing the amount of LDL removed by the
blood stream
Side effects: Myalgias, delirium, dementia
Nutritional Deficiencies and Eating Disorders
> 100cm Resection = Bile salt deficiency & fat malabsorption
< 100cm Resection = Bile-acid induced diarrhea (secretory diarrhea with hyperabsorption of oxalate
kidney stones)
Trace Minerals
ZINC SELENIUM
DEFICIENCY TOXICITY DEFICIENCY TOXICITY
Taste Loss N/V & Diarrhea Cardiomyopathy Hair Loss
Hair Color Change and Loss Abdominal Pain Skeletal Muscle Dysfunction Tooth Decay
Rash (Acro-orificial) Copper Deficiency Nail Changes
Neurologic
(MS changes, peripheral
neuropathy)
Lab = Plasma Zinc Lab = Serum Selenium
Lab = Blood Glutathione Peroxidase Activity
IODINE COPPER
DEFICIENCY TOXICITY DEFICIENCY TOXICITY
Hypothyroidism Hyper- or Hypothyroidism Pancytopenia Hepatic Necrosis
Mental Slowing Goiter Fractures Renal Failure
Delayed Development Neurologic (Ataxia, Neuropathy) N/V & Abdominal Pain
Coma
Lab = Urine Iodine Lab = Serum Copper
Lab = TSH Lab = Plasma Ceruloplasmin
CHROMIUM MANGANESE
DEFICIENCY TOXICITY DEFICIENCY TOXICITY
Glucose Intolerance Rash with Skin Ulcers Hair Color Change Neurologic (Parkinson's-like)
Bronchogenic CA Sexual Dysfunction
Lab = Serum Chromium Cramps
Lab = Glucose Tolerance Test Lab = Serum Manganese
IRON FLUORIDE
DEFICIENCY TOXICITY DEFICIENCY TOXICITY
Anemia N/V & Diarrhea Tooth Decay N/V & Diarrhea
(microcytic, hypochromic) Hepatic Necrosis Hypersalivation
Shock (all 3) Seizures
Lab = Serum Fe, TIBC, Ferritin CP Arrest
Pazirandeh S & Burns DL. UpToDate – 2006
Arrythmias
Anything that is above the His bundle is considered Supraventricular and anything below is called
ventricular
Sinus arrhythmia
o Irregularity of the normal sinus rhythm that originates from the sinus node, usually in young and
healthy individuals and is not pathologic but a product of vagal tone
Sinus bradycardia
o Secondary to vagal tone or sinus node disease
Sinus tachycardia
o Physiolgoy response to exercise usually, dehydration
Inappropriate sinus tachycardia
o Persistent, rate is high, cannot be explained by physiologic demands
Sick Sinus Syndrome
o Tachycardia, Bradycardia
o Pts can have chronotrophic incompetence inappropriately low HR responses to physiologic
demands
If someone has an arrhythmia of sinus origin IF they have symptoms put in a pacemaker
Tachyarrhythmia
o
o Remember that tachyarrhythmias occur from usually 2 reasons
Focal arrhythmias: repetitive firing of a group of cells
o Reentry: the continuous cycling of an electrical impulse in any cardiac tissue
o
A flutter vs A fib
o A flutter is a reentry circuit that keeps looping around hence producing the saw-tooth pattern
Ablation is the preferred method and has a very high success rate as compared to AF
o A fib is not it is just multiple foci firing at once
No P waves on EKG and patients have an irregular rhythm
o
o Treatment: Rate control over rhythm BB, CCB, Digoxin
Long term ablation or cardioversion
o
REMEMBER if they have valvular afib you should immediately start them on warfarin
Paroxysmal SVT
o
AVRT vs AVNRT
o Treatment patients can usually do carotid sinus massage to slow the AV node and bring
themselves out of their tachycardia
o Definitive treatment is ablation
AV Block
o
Congenital Heart Disease
Older the patient is at the time of CoA repair the higher the incidence of systemic HTN after surgery is
Transfusion 2
The Most Common transmitted infection is bacterial contamination!
Septic Tranfusion Reaction/Bacterial Contamination of the Product
o Most commonly from platelets, then RBCs, uncommonly plasma
o Abrupt and severe onset
o Treatment: STOP TRANFUSION, NOTIFY BLOOD BANK, BROAD SPECTRUM
ANTIBIOTICS
Alloimmunization
o Allo vs autoantibodies
Alloantibodies Antibodies against foreign RBC antigens that the patient doesn’t
express
Autoantibodies Antibodies against self RBC antigens that are present on the patient’s
own RBCs
o Can be clinically significant Antibody is capable of causing hemolytic transfusion rxns,
hemolytic disease of the fetus
o Alloimmunization is highest in sickle cell disease patients!!
o IgM antibodies against RBC antigens are usually naturally occurring (intravascular hemolysis)
o IgG antibodies against foreign antigens are from transfusion or pregnancy (extravascular
delayed hemolysis)
o