Sytems 5a.txt

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  1. What 3 categories of disease cause anemia?
    • 1. blood loss
    • 2. RBC production
    • 3. destroy RBC
  2. What are tests for anemia?
    • Hematocrit: low 40's (lower for females)
    • erythrocyte 5M/uL
    • evaluate Hg
  3. What are 3 classes of anemia?
    • normo: loss/decrease prod
    • micro: Fe (hypochrom)
    • macro: (B12, folate)
  4. What are the intraoral signs of anemia?
    • red, sore, smooth tongue(atrophy papillae)
    • esophageal webs and dysphagia
    • oral mucositis
  5. What are therapies for microcytic anemia?
    Fe replacement: ferrous sulfate(uncomplicated, 3-8weeks), deferoxamine(chelating, acute)
  6. What enzyme converts homocysteine to methionine?
    • hydroxocobalamin to methylcobalamin
    • methionine synthase
  7. What enzyme is necessary for folates role in DNA synthesis?
    DHF reductase (DHF->THF) (di->tetra)
  8. What is diff in clinical presentations of B12 and folic acid def?
    • Both: pallor, anemia, fatigue, glossitis
    • B12: neuro (myelin synthesis)
  9. Exposure to what compound results in megaloblastic anemia?
    NO: inhibit methionine synthase
  10. What are the causes of folic acid deficiency?
    • malabsorption, overcooking, maternal, hepatic(alcohol)
    • drugs: phenytoin, oral contraceptives, antimalarials
    • DHF reductase inhibitors(cancer, autoimmune): methotrexate, trimethoprim
    • leucovorin counteracts DHF reductase inhibitors
  11. What are the classes of antithrombic drugs?
    • 1. anticoagulants: warfarin(coumadin), pradaxa, heparin (thrombin inhibitor)
    • 2. antiplatelet: aspirin, clopidogrel, dipyridamole
    • 3. thrombolytic (fibrinolytic):
  12. What is the difference between low and high conc of heparin?
    • low: accelerate antithrombin III (1000x) inactivating 9,10,12
    • high: hep/antithrIII binds thrombin itself
    • all parenteral admin
  13. What is the heparin antagonist?
    protamine sulfate
  14. What are the indirect anitcoags?
    • coumadin (warfarin)
    • inibit reduction of Vit K (necessary for gamma carboxylation of 2,7,9,10)
    • SE: hemmorhage
    • Int: antimicrobials, barbituates (inc met), NSAIA (sensitize)
  15. what does vit K do?
    cofactor in gamma carboxylation of glutamic acid residues of clotting factors 2,7,9,10
  16. What drugs are platelet inhibitors?
    • Aspirin: (cyclooxygenase)TXA2 inhibitor
    • Clopidogrel: ADP receptor antagonist (no agg)
    • Dipyridamole: vasodilation, PDEase inhib->inc CAMP, less agg
  17. What are fibronolytic drugs?
    • plasmin: lyses fibrin, degrades factors 5,8
    • plasminogen activators: t-PA (3 hour window) adheres fibrin, absorbs and cleaves plasminogen
    • urokinase: activates circualting plasminogen
    • steptokinase: (exotoxin) binds and kinda activates plasminogen
    • anistreplase: streptokinase & acylated plasminogen
    • uses: MI, pulm emb, DVT
  18. How long should pt on aspirin or coumarin stop b4 procedure?
    • aspirin: 5 days, start 1 day after
    • coumarin: INR (international normalized ratio) 2.5 (5 bad, 1 avg)
    • heparin: 6 hours or reverse w protamine, restart after clot formed
  19. Which blood disorder pts are of particular concern for dentist?
    • leukopenia: drug, chemo, cyclic neutropenia
    • lekemias & lymphomas: dysfunctional WBC
  20. What are important lab values to asses hematologic status?
    • RBC: stress
    • WBC: infection (osteomyleitis after extractions, antibiotic prohy)
    • Platelets: hemostasis
  21. What precautions should be done for pt on chemo?
    • done befor chemo/radio
    • CHX, antifungal rinses
    • treat during intervals
    • early after diagnosis
  22. What does aPTT assess?
    • partial thromboplastin time (30+-5 seconds)
    • Intrinsic: 1,2,5,8,9,10,11,12 (8 most imp)
    • heparin levels
  23. What test is used to assess LMWH levels?
  24. What are thrombophila causes?
    • V mutation
    • prothrombin mutation
    • def of protein C, S or antithrombin
    • acquired: inflammation (TF)
  25. Consequences of DIC?
    • bleeding: depleted factors, platelets
    • thrombosis: organ failure (infarcs)
  26. What does PT assess?
    • prothrombin time: 13 secs+-1
    • Extrinsic: 1,2,5, 7*, 10
    • INR: international normalized ratio = pt PT/mean lab PT adj w/ international sensitivity
    • warfarin/coumadin levels
  27. Describe platelet ranges.
    • <5,000 GI or cerebral hemmorhage
    • <20,000 spontaneous bleeding
    • >50,000 needed for surgical hemostasis
    • <100,000 thrombocytopenia
    • 150,000-300,000 normal
    • life span 10 days
  28. What is bleeding time evaluate?
    • qualitative platelet function & vascular integrity
    • 40mm Hg BP cuff and incision blotted every 30 secs
    • 5 min +- 2 (longer 9.5 if aspirin)
  29. What is PFA-100?
    main test: platelet ability to aggregate to collagen-epi & collagen-ADP
  30. What is are other qualitative platelet tests?
    • platelet aggrometry: agg w/ ADP, collagen, Arachidonic acid, or EPI
    • ultegra: bind fibrinogen
  31. Heriditary coagulation disorders?
    • Hemophilia A/B
    • vWF disease
    • afirongenememia
    • v, VIII def
    • hemorrhagic telangicastia
    • Protein C def
    • antithrombin III def
  32. DIC triggers.
    • intravascular activation
    • cellular procoags: TF, cell lysis
    • vascular factors: endothelial damage, hypotension/stasis shock
  33. Acquired coag disorders?
    • Vit K def
    • drug-induced hemmorhage, platelet
    • blood transfusion
    • post bypass
    • DIC
    • idiopathic or thrombotic thrombocytopenic purpura
  34. Thrombocytopenia treatments?
    platelet transfusion
  35. vWF disease?
    • vWF is carrier for Factor VIII (inc half life and conc)
    • low plasma vWF released from endothelium and platelets
    • types (I, IIA, IIB, III)
    • bleeding persists (usually diagnosed via dental)
    • mild tx: desmopressin (DDAVP)
    • moderate: viral factor VIII-vWF, cryoprecipitate(disease tx), antifibronlytics
    • no aspirin/NSAIDS, acetomenophin& opiods OK
    • coagulation adjuncts should be available
  36. What are some antifibrinolytics?
    • plasminogen activator inhibitors
    • rinses of tranexamic acid
  37. Is aspirin a dental procedure concern?
    not really, NEVER stop for pts w/ Coronary artery stents
  38. How many half lifes will NSAIDS be cleared?
    4: 94% clearance
  39. What are plavix(clopidogrel) and prasugrel(effient) dental concerns?
    • active metabolites
    • less bleeding problems than aspirin
    • do not D/C
    • never for stents
    • if D/C need 6 days
  40. Hemophilia?
    • X linked recessive (males only, female carriers)
    • Hemophilia A: (VIII def) 80%
    • Hemophilia B: (IX def) 15%
    • early hemostasis may bleed late
    • watch out for Deep IM injections (IAN)
    • tx: replace factors & antifibrinolytics, no aspirin/NSAIDs
  41. For hemophilia what levels of VIII do you need for dental surgery?
    • >40% general
    • 80-100% for major oral
    • use advate or cryoprecipitate
  42. What does coumadin do?
    • warfarin: competitive antagonist of vit K (epoxide reductase) 2, 7, 9, 10
    • many interactions
    • uses: DVT, post pulm emb, A-fib, Post MI/CVA, prosthetic valves
    • asses PT/INR usually ok <3
  43. What are the aids to coagulation?
    • pressure packs
    • aggregation promoters: geleini, collagin, collagen-like
    • coagulation promoters: thrombostat
  44. What should acetaminophen be limited to for pts on coumadin?
  45. What are the dental concerns for heparin and LMWH?
    • won't typically see hep
    • LMWH: against Xa (enoxaparin) DVT, pulmonary embolus
    • delay dental tx if possiible, consult MD
    • useful as bridge D/C coumadin and start lovenox
  46. NHL is what % of new cancers?
    • 4
    • 6th most common cause cancer death
    • increasing incidence/mortality
  47. What are the mechanisms of lymphomagensis?
    • genetic alterations:
    • infection: (H. pylori, Chlamydia psittaci, EBV(burkitts), HTLVI (Tcell) HTLV-V (cutaneous T-cell), Hep C
    • antigen stim: Sjogrens
    • immunosuppression: wiskott-aldrich, organ, AIDS, age
  48. Clincal behavior classifications of lymphoma?
    • low grade: indolent, incurable, years life expectancy (CLL,hairy cell)
    • intermediate: aggressive
    • high grade: very aggressive, potentially curable, weeks life expectancy (ALL, burkitts)
  49. Clinical features of lymphomas?
    lymphadenopathy (may fluctuate), cytopenia, hepatosplenomegaly, fever, night swears, weight loss
  50. What is a waldeyer's ring a sign of?
    GI lymphoma
  51. What does a biopsy for NHL evaluate?
    • morphology and nodal architecture
    • immunohistochemistry: reveal monoclonal
  52. What are important chromosomes involved with NHL?
    • bcl-2 (14,18 trans follicular lymphoma)
    • c-myc (Burkitts)
    • cyclin D1 (mantle cell)
  53. What is counterintuitive about indolent lymphoma treatement?
    • stage III (both sides diaphragm) and IV(marrow) are highly curable
    • wait til symptomatic to treat
  54. What is the most common indolent lymphoma?
    • follicular (bcl-2 absent) germinal center B-Cell
    • translocation (14,18) fuses bcl-2 and IgH constitutively expressed
  55. What is rituximab?
    immunotherapy- monoclonal CD20 (B-cells) Ab
  56. Does immediate treatement prolong survival of Follicular cell lymphoma?
  57. What is Diffuse large B-cell lymphoma(DLBCL)?
    • most common aggressive lymphoma
    • usually symptomatic, extranodal, germinal center B-cell
    • curable 60-75%
    • rapidly enlarging mass(nodal)
    • elevated LDH
    • BCL-2,6
  58. What is the treatment course for DLBCL?
    • R-CHOP
    • Rituximab
    • cyclophoshamide
    • hydroxydaunorubicin
    • oncovin
    • prednisone
  59. What is Burkitt's lymphoma?
    • EBV associated
    • abdominal, rapidly growing mass/tumor
    • c-myc oncogene linked with Ig genes
  60. What is hodgkin's disease?
    • highly curable, not as common, Reed-Sternberg cells(giant B cells (popcorn), some w/EBV genomes)
    • more common for rich, young(>50 bimodal)
    • Pel-Ebstein fever(relapsing high-grade)
    • painful to drink alcohol
    • Predictable: cervical->mediastinum or axilla
    • tx: ABVD, BEACOPP
    • ABVD: adriamycin, bleomycin, vinblastine, dacarbazine
    • sensitive to Radiation
  61. What is a thick buffy coat a sign of?
    too many WBCs and platelets
  62. Leukemia features?
    • neoplastic, unregulated accumulation or proliferation of WBCs
    • assess: cell line, maturatation, chronic, acute
  63. What are the granulocytes?
    • myeloid progenitor
    • BEN, baso, eosin, neutro
  64. What are the agranulocytes?
    • lymphoid progenitor
    • lymphocyes, monocytes
  65. CML features?
    • leukocytosis
    • philly chromosome
    • active tyrosine kinase
    • anemic symtpoms (splenomegaly)
    • all stages of myeloid(B,E,N), giant platelets
    • low leukocyte alkaline phosphotase
    • high B12 binding
  66. What is philadelphia chromosome?
    • abnormal 9-22 translocation
    • BCR-ABL on 22 w always active tyrosine kinase
  67. What are CML treatments?
    • imantinib, (-inibs)
    • marrow transplants, chemo
    • no tx for blast crises
  68. What are features of acute leukemias?
    • generally unknown causes
    • block of maturation, many immature blasts
    • blasts in periphery, inc buffy coat, pancytopenia (mature) hypercellular, monotonous marrow
    • petichiae
    • AML increase w/age, ALL decrease then increase
  69. AML features?
    • myeloblasts ubiquitous
    • anemia, thrombo, neutorpenia
    • leukemic infiltration
    • 3-6 months survival
    • translocation are favorable
    • diploid, -Y is most common (intermediate prognosis)
  70. Which leukemia presents w gum hyperplasia?
    • M4-myelomonocytic
    • M5- monoblastic
  71. AML treatment?
    induction: cleared but could come back, follow w/ consolidation or transplant
  72. APL features?
    • M3- acute promyelocytic
    • DIC (from granules release)
    • t(15,17) 90% treatable w/ vitamins
  73. What are the features of ALL?
    • most common of children (peak 3-4 yr old)
    • adults usually relapse
    • marrow and blood lymphoblasts
    • CNS involvement
    • 70% cureable in children(chemoradiation)
    • L1: big no cytoplasm
    • L2: large w/more cytoplasm
    • L3: burkitts, big w/ vacuoles
  74. What are oral complications of acute leukemias?
    • leukemic infiltration-> gum hyperplasia: moncytic leukemias
    • mucositis: chemo, radiation, neutropenia
    • infections: abcess, herpes, candida
    • bleeding: peticea, gingival
    • graft vs host: mucostis, infection, secondary tumors
  75. CLL features:
    • small mature lymphocytes in blood
    • hypercellullar marrow w mature small lymphocytes
    • treat only if symptomatic
    • Painless lymph nodes
  76. Multiple myeloma
    • proliferating neoplastic PLASMA cells (crowds out other cells->pancytopenia)
    • clonal and produce monoclona Abs (found in blood and urine)
    • proliferate in marrow and cause skeletal destruction (radiolucent xrays)
    • hyperviscosity
    • hyperglobulinemia
    • Rouleaux formation of RBCs (stuck in rows)
    • excess bleeding light chains
  77. Multiple myeloma tx?
    • thlidomide, lenaldomide
    • radiation
    • transplant
  78. Which marker indicates stem cells?
  79. What is usually the most histocompatible relative?
    • sibling
    • class I: A,B,C
    • Class II: DR
  80. What endothelial secretions inhibit platelet aggrigation?
    prostacyclins (PG2)
  81. what is the catalyst of fibrinogen?
  82. Describe the intrinsic pathway.
    • 12, 11, 9 (8) 10, V (prothrombin), 1 fibrinogen 13
    • all factors in blood
    • activation: damaged surface
  83. What sets off the extrinsic pathway?
    • tissue factor from fibroblast membranes (trauma)
    • initiatesclotting transient because VIIa is inhibited
  84. What factor is typically used to speed clottiing?
    recombinant VIIa
  85. what does thrombin do?
    • activates fibrinogen
    • cleave thrombin receptor (activates platelets)
    • cleave V adn VIII
    • limit by cleaving Va and VIIIa
  86. what else do platelets do?
    release growth factors that facilitate healing
  87. what are the natural clotting limiters?
    • thombomodulin (protein C & S) hydolize Va, VIIIa
    • antithrombin & 2a and 10a & heparin- antithrombin inactive protease complex
  88. Role of vit k?
    • 2,7,9, 10, C, S
    • glutamate residues (gamma carboxylation)
    • coumadin (oral) (K blocker)
  89. what is a tPA drug name?
  90. What are D-dimes?
    • biproducts of plasmin breakdown of clots
    • DIC
  91. What are some embryological milestones of hematopoiesis?
    • 3 wks: yolk sac stem cells
    • 3 months: migrate to liver (some in spleen, lymphoid dev in nodes and thymus
    • 4 months: migrate to bone marrow (func after 7 mo)
    • birth: cord blood w/hematopoietic stem cells
    • 2 wks postpartum: hematopoiesis shifts to marrow
  92. What hormone controls RBC production?
    • erythropoietin: kidney, O2
    • nutrients: Fe, B12, Folate
    • normal bone marrow
    • proerythroblast->basophilic eb->polychromatic eb-> normoblast
  93. What is a reticulocyte?
    immature RBC, no nucleus, reticular(mesh) rRNA (methylene blue)
  94. What is the protein of the cytoskeleton of RBC?
  95. What are normal lab ranges for erythron for males and females?
    • name, male, female (lower numbers)
    • RBC: 4.4-5.9, 3.8-5.2
    • Hemoglobin: 13-18, 12-16
    • hematocrit: 40-52, 35-47
    • reticulocytes: 0.5-1.5%, 0.025-0.105/mm3
  96. What are the normal ranges of RBC indices?
    • MCV: avg volume 80-100
    • MCHC= avg Hg/volume 31-36
    • MCH: avg weight 27-34
  97. What are the presentations of iron deficiency anemia?
    • hypochromic, microcytic
    • most common (cause chronic blood loss, menorrhagia, intesinal)
    • Fe absorbed in duodenum (malabsorbtion sprue, celiac)
    • transferrin: transport protein
    • no active Fe excretion
    • ferritin(best indicator) & hemosiderrin: storage protein
    • dimple is 1/2 cell when should be 1/3rd
    • pica: desire to eat nonedible
  98. What is pica?
    desire to eat non-edible, consequence of Fe def anemia
  99. What are oral presentations of anemia?
    • sore tongue
    • angular chelitis
    • aphtous ucerations
    • atrophic mucositis of upper aero-digestive tract
  100. What are the causes of anemia of chronic disease?
    • infection: TB, osteomyelitis
    • immune disorders: rheumatoid arthritis, regional enteritis
    • neoplasms: lymphoma, carcinoma
    • All increase IL which inhibit rls of Fe from stores and decrease erythropoeitin response
  101. What are the causes of megaloblastic anemia?
    • B12 and folic acid deficiency
    • req for DNA synth, delay nuclear maturation w respect to cytoplamic elements
    • (hypercelluar) megaloblasts in marrow, macrocytic RBC & hypersegmented neutrophils in blood
  102. What is the function of folic acid?
    • C1 fragment tranfer
    • rate limiting: deoxyurdilate+ c1 frag--> thymidilate
  103. What causes folic acid deficiency?
    • diet, alcohol, metabolic needs, drugs (anticonvulsants, antimicrobials, methotrexate)
    • malabsorbtion: celiac, sprue
  104. What is the function of B12?
    cofactor in thymidilate synthesis, cofactor in methylmalonyl CoA to Succinyl CoA
  105. What is required to absorb B12?
    • intrinsic factor: cofactor of gastric parietal cells)
    • receptor in terminal ilial
    • transcobalamin: transport protein
  106. What is pernicious anemia?
    deficient(autoimmune) intrinsic factor (B12)
  107. What are some causes of B12 deficiency?
    • pernicious, malabosbtion, competition (tapeworm), diverticulosis
    • rarely dietary or hereditary
    • poikilocytes & megoblastc marrow
  108. Describe the classifications of hemolysis.
    • intravascualar
    • extravascular: spleen
    • intracorpuscular: intrinsic deficient
    • extracorpuscular:
  109. What are the byproducts of hemoglobin after hemolysis?
    • Fe: transerrin back to bone marrow
    • porphyrin: indirect, unconjugated bilirubin
    • globin: digested to AA
    • CO
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Sytems 5a.txt
S5 pt 1
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