Sytems 5a.txt

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Sytems 5a.txt
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2012-08-09 02:56:15
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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?
    anti-Xa
  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?
    2gms/day
  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?
    no
  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?
    CD34
  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?
    thrombin
  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?
    ateplase
  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?
    spectrin
  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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