Grand Rounds (week 7): Dr Kate Wiggin on Hematology
I'm not taking notes on the cases themselves, just on factoids.
TBI
TBI-->3x greater risk if 2nd injury, 8x more subsequent
URINE
high dose vit C negates these 4 UA values: gluc, blood, bili, nitrates
see hematuria 3x-->get more dx, cystoscopy
GUT BUGS
strep in GI: requires blood to live, no blood, no strep
Klebsiella found in 40% of human guts, if moderate then slight concern
HEMOCHROMATOSIS
dx = ferritin over 200 in menstruating women, over 300 in men or postmeno female
TIBC tends to decrease, serum Fe is high, saturation is high
iron storage in: RBCs, Liver, macrophages, BM, myoglobin
DDX: infx lowers serum Fe: if IL1 and IL6 are elevated then ferritin is moved into macrophages (sequestration)
DDX: ferritin = acute phase reactant prot, increased with liver dz, infx, inflam, malig
DDX for high iron with overload: hemochromatosis, alcohol excess, porphyria cutanea tarda (enz in heme catab malfx)
GENETICS: HFE gene on Xsm 6 has 11 products, expressed in liver, intestine and immune system cells
who gets HH: males 40-60, northern Eur descent
incidence in US: 5/1000 genetic
C282Y genotype carries dz, H63D mutation not associated with hemochromatosis unless heterozygous with 282Y
DDX: incr Fe without overload: NASH, hep B/C, alc, chronic infx, RA, IBD, hematologic malig, thyrotoxicosis
IL4 and IL13 enhance Fe uptake and storage (Th2)
BREAST CA
maintaining healthy BMI increases prognostic status
stages: 0-4, 4 is advanced/mets
FOR LOW FE
topical ferrous sulfate compounded at 200mg/gram
sig: apply 1g qd x3mo to wrists, thighs, armpits
SE: may turn teeth/fingernails gray, brush with baking soda
good for peds or people with constip prob
has a scent
MATURATION OF A RBC
rubriblast-->pro-->cyte (makes HGB)-->meta (looses nucleus)-->reticulocyte (matures in 24 hours)-->erythrocyte (lives 120 days)
WHY ARE RETICS IMP?
esp in ca pt who has been txd with chemo, rad?
RI, retic index is caculated to assess bone marrow fx in anemia
RI = retic% x pt's HCT/normal HCT x 1.1.85
normal HCT for females given as 45
(in case calculated value is 0.29, less than 2 means not enough bone marrow prolif)
VITAMIN D
vit D comes in 100,000 IU/ml compounded D2 for injx
she injx 1/2 ml/week for pts in need
B12
gives weekly shots to pts with bone marrow probs
if serum level is high with little response: test to see if it is utilized: MMA in urine
gives breakdown products to know if it's being used
GILBERT'S DZ
icterus intermittentus
mc hereditary cause of incr bili
~5% of pop, dental journals say up to 10%
elevated unconjugated bili
decr glucuronyl transferase enzyme which solubilizes bili in liver
20% conjugated in intestine, spike in tbil after round of abx kill off gut bugs?
sx: fatigue, poor concentration, loss of appetitie, abd pain, wt loss
assoc c decreased coronary artery disease
watch bili, indirect bili, and MCV
tx: consider LDN to decrease inflammation (upregs enkephalins during sleep)
naltrexone at 100-200mg/d is addicting, she uses doses of 2-4mg qhs
tx: B12 and folate galore
HASHIMOTO'S THYROIDITIS
consider LDN for this too
iodine and selenium needed by thyroid
heavy metals can interfere with uptake and integration
TBI
TBI-->3x greater risk if 2nd injury, 8x more subsequent
URINE
high dose vit C negates these 4 UA values: gluc, blood, bili, nitrates
see hematuria 3x-->get more dx, cystoscopy
GUT BUGS
strep in GI: requires blood to live, no blood, no strep
Klebsiella found in 40% of human guts, if moderate then slight concern
HEMOCHROMATOSIS
dx = ferritin over 200 in menstruating women, over 300 in men or postmeno female
TIBC tends to decrease, serum Fe is high, saturation is high
iron storage in: RBCs, Liver, macrophages, BM, myoglobin
DDX: infx lowers serum Fe: if IL1 and IL6 are elevated then ferritin is moved into macrophages (sequestration)
DDX: ferritin = acute phase reactant prot, increased with liver dz, infx, inflam, malig
DDX for high iron with overload: hemochromatosis, alcohol excess, porphyria cutanea tarda (enz in heme catab malfx)
GENETICS: HFE gene on Xsm 6 has 11 products, expressed in liver, intestine and immune system cells
who gets HH: males 40-60, northern Eur descent
incidence in US: 5/1000 genetic
C282Y genotype carries dz, H63D mutation not associated with hemochromatosis unless heterozygous with 282Y
DDX: incr Fe without overload: NASH, hep B/C, alc, chronic infx, RA, IBD, hematologic malig, thyrotoxicosis
IL4 and IL13 enhance Fe uptake and storage (Th2)
BREAST CA
maintaining healthy BMI increases prognostic status
stages: 0-4, 4 is advanced/mets
FOR LOW FE
topical ferrous sulfate compounded at 200mg/gram
sig: apply 1g qd x3mo to wrists, thighs, armpits
SE: may turn teeth/fingernails gray, brush with baking soda
good for peds or people with constip prob
has a scent
MATURATION OF A RBC
rubriblast-->pro-->cyte (makes HGB)-->meta (looses nucleus)-->reticulocyte (matures in 24 hours)-->erythrocyte (lives 120 days)
WHY ARE RETICS IMP?
esp in ca pt who has been txd with chemo, rad?
RI, retic index is caculated to assess bone marrow fx in anemia
RI = retic% x pt's HCT/normal HCT x 1.1.85
normal HCT for females given as 45
(in case calculated value is 0.29, less than 2 means not enough bone marrow prolif)
VITAMIN D
vit D comes in 100,000 IU/ml compounded D2 for injx
she injx 1/2 ml/week for pts in need
B12
gives weekly shots to pts with bone marrow probs
if serum level is high with little response: test to see if it is utilized: MMA in urine
gives breakdown products to know if it's being used
GILBERT'S DZ
icterus intermittentus
mc hereditary cause of incr bili
~5% of pop, dental journals say up to 10%
elevated unconjugated bili
decr glucuronyl transferase enzyme which solubilizes bili in liver
20% conjugated in intestine, spike in tbil after round of abx kill off gut bugs?
sx: fatigue, poor concentration, loss of appetitie, abd pain, wt loss
assoc c decreased coronary artery disease
watch bili, indirect bili, and MCV
tx: consider LDN to decrease inflammation (upregs enkephalins during sleep)
naltrexone at 100-200mg/d is addicting, she uses doses of 2-4mg qhs
tx: B12 and folate galore
HASHIMOTO'S THYROIDITIS
consider LDN for this too
iodine and selenium needed by thyroid
heavy metals can interfere with uptake and integration