Malignant Qu 1
You SHO phones you for advice. They have been asked to review a 35 year old man who started his steroid pre-phase for ALL yesterday. The patient complained of palpitations and an ECG shows some T wave abnormalities.
What do you suspect and how will you proceed?
R/v fluid balance
ABG + Bloods
Cardiac monitoring + reverse K+
Contact Renal / ITU
What are the diagnostic criteria for TLS?
Lab: 2 or more of:
Uric acid >476 or 25% above baseline
K+ >6.0 or 25% above baseline
Phos >1.45 or 25% above baseline
Calcium <1.75 or 25% below baseline
Clinical: Lab plus one of:
Creatinine >1.5x ULN
Can you give me any examples of risk factors for TLS?
High tumour burden
High grade tumours (ALL, BL)
Pre-existing renal impairment
Cell cycle specific chemotherapy
Other drugs – alcohol, Vit C, aspirin, Caffeine, Cisplatin, Thiazides, Levodopa, Phenothiazines, theophylline
Can you tell me how rasburicase works?
Exogenous recombinant urate oxidase
Converts uric acid —> allantoin, 10x more soluble
What is the dose in prophylaxis?
Malignant Qu 2
A GP refers a 57 year old man to you with a Hb 170, Hct 0.53, plt 320, WBC 6.0.
How would you approach the investigation of this patient?
Repeat test with adequate hydration
Hx & Ex
O2 sats, BP, urine dip
FBC, Film, U&E, LFT
JAK2 Mutation (V617F, Exon 12)
If JAK2 neg – RCM, Epo, ABG, USS, BM Bx, Cytogenetics, PFTs, Sleep Study, VHL gene
The patient is positive for the JAK2 V617F mutation. Can you tell me about any diagnostic criteria for PV?
WHO vs BCSH
WHO: 3 major (Hct >0.49 / 0.48 M:F, BM Biopsy, JAK2+) or 2 major plus low Epo
How will you manage this patient?
Reduce thrombosis and haemorrhage
Reduce risk of MF / AML
Starts aspirin 75mg OD, Venesect to Hct <0.45, control CVS risk factors
Would you not start cytoreduction?
BCSH – poor tolerance of venesection, progressive splenomegaly, thrombocytosis, constitutional symptoms
ELN – Age >60, Plt >1500, Prev thrombosis
Three years later patient is still venesection dependent as he did not tolerate hydroxycarbamide and he is now experiencing early satiety and LUQ discomfort. Would you give him ruxolitinib?
RESPONSE 2015 —> licensed for HU resistant/intolerant PV. 222 patients, complex study.
RELIEF 2014 – no better than HU
MAJIC 2016 – results awaited
Coag Qu 1
Tell me the principle of preforming an activated partial thromboplastin time
Blood collected into citrated tube.
Centrifuged to produce PPP
PPP + Activator + Phospholipid, incubated at 37oC
Add calcium and time to clot
Tell me about the method or analyser your lab uses for this?
ACL Top, Silica activator, change in optical density
What is Quality Assurance and how does your lab ensure that is provides its service users with quality APTT results?
QA = Planned and systemic activities to provide adequate confidence that requirements for quality are met. Aims to provide a product that is Accurate, Reliable and Reproducible.
Internal: Staff proficiency, Quality management System (Q-Pulse), Audit, Education
External: EQA, voluntary accreditation (UKAS to ISO standard 15189:2007)
Your lab manager phones you and tells you that your most recent NEQAS submission has been returned as outwith consensus. You reported an APTT of 36 seconds, compared to the method median of other labs which reported 43 seconds. What would your initial actions be?
Think pre-analytical, analytic and post-analytic errors when giving your answer
Look for typographical error in submitting the result to NEQAS - this is a common cause of an apparently serious discrepancy which hasn’t otherwise become apparent from the clinical use of the results you have been reporting in the time since submitting your NEQAS result.
Repeat test if sample still available
In the (unlikely) event of a genuine problem with analyser this will need an urgent response. Think CAPA (Corrective Action, Preventative Action) when discussing your response.