index.html (10266B)
1 <!DOCTYPE html> 2 <html lang="en"> 3 <head> 4 <link rel="stylesheet" href="/style.css" type="text/css"> 5 <meta charset="utf-8"> 6 <meta http-equiv="Content-Type" content="text/html; charset=utf-8"> 7 <meta name="viewport" content="width=device-width, initial-scale=1.0"> 8 <link rel="stylesheet" type="text/css" href="/style.css"> 9 <link rel="icon" href="data:image/svg+xml,<svg xmlns=%22http://www.w3.org/2000/svg%22 viewBox=%220 0 100 100%22><text y=%22.9em%22 font-size=%2290%22>🏕️</text></svg>"> 10 <title></title> 11 </head> 12 <body> 13 <div id="page-wrapper"> 14 <div id="header" role="banner"> 15 <header class="banner"> 16 <div id="banner-text"> 17 <span class="banner-title"><a href="/">beauhilton</a></span> 18 </div> 19 </header> 20 <nav> 21 <a href="/about">about</a> 22 <a href="/now">now</a> 23 <a href="/thanks">thanks</a> 24 <a class="nav-active" href="/posts">posts</a> 25 <a href="https://notes.beauhilton.com">notes</a> 26 <a href="https://talks.beauhilton.com">talks</a> 27 <a href="https://git.beauhilton.com">git</a> 28 <a href="/contact">contact</a> 29 <a href="/atom.xml">rss</a> 30 </nav> 31 </div> 32 <main> 33 <h1> 34 Morning Report 08/23/2021 35 </h1> 36 <p> 37 <time id="post-date">2021-08-23</time> 38 </p> 39 <p> 40 Details modified, generalized, and otherwise fudged to be 41 HIPAA-compliant. 42 </p> 43 <h2> 44 HPI 45 </h2> 46 <p> 47 72F with chest pain, abdominal pain, and constipation. 48 </p> 49 <p> 50 2-3mo weight loss, night sweats. 51 </p> 52 <p> 53 2-3wk +perineal ?cyst, initially ttp and hurt to walk, but now 54 nontender. 55 </p> 56 <p> 57 ~1wk constipation, BRB on TP. 58 </p> 59 <p> 60 +crampy LLQ pain 8/10, x3-4 days, improves with positioning (supine 61 with head raised somewhat, 3-4 pillows). 62 </p> 63 <p> 64 +LUQ and left-sided chest pain x1-2 days, radiates to L arm, not 65 related to exertion, lasts a few minutes. 66 </p> 67 <h2> 68 OP Meds 69 </h2> 70 <ul> 71 <li> 72 duloxetine 60mg 73 </li> 74 <li> 75 ASA 81mg 76 </li> 77 <li> 78 melatonin 6mg 79 </li> 80 <li> 81 no notable allergies 82 </li> 83 </ul> 84 <h2> 85 PMSHx 86 </h2> 87 <ul> 88 <li> 89 TVH-BSO for fibroids and endometriosis (~20y ago) 90 </li> 91 <li> 92 hemorrhoids (no surgeries) 93 </li> 94 <li> 95 s/p Moderna COVID vaccine (~4wk ago) 96 </li> 97 <li> 98 UTD on mammograms, colonoscopies, no deviations from regular 99 schedule 100 </li> 101 </ul> 102 <h2> 103 SHx 104 </h2> 105 <ul> 106 <li> 107 monogamous x45y, G2P2 sons, 6yo grandson, all healthy 108 </li> 109 <li> 110 never smoker 111 </li> 112 <li> 113 social EtOH, none this year 114 </li> 115 <li> 116 no non-Rx medicines 117 </li> 118 <li> 119 previously secretary 120 </li> 121 <li> 122 likes to DIY: painting, home crafts, gardening 123 </li> 124 </ul> 125 <h2> 126 FHx 127 </h2> 128 <ul> 129 <li> 130 M GM: uterine cancer (~40yo) 131 </li> 132 <li> 133 P GF: lung ca, unknown type (~70yo) 134 </li> 135 </ul> 136 <h2> 137 PE 138 </h2> 139 <ul> 140 <li> 141 VS: wnl 142 </li> 143 <li> 144 GEN: NAD 145 </li> 146 <li> 147 HEENT: no LAD 148 </li> 149 <li> 150 PULM: fine 151 </li> 152 <li> 153 CV: fine 154 </li> 155 <li> 156 ABD: NTND, +splenomegaly 157 </li> 158 <li> 159 GYN: 0.5cm lesion R side of anterior perineum, NT, freely 160 mobile 161 </li> 162 <li> 163 NEURO: fine 164 </li> 165 </ul> 166 <h2> 167 Labs 168 </h2> 169 <ul> 170 <li> 171 Hgb 12.7 172 </li> 173 <li> 174 WBC 58.3 175 <ul> 176 <li> 177 0 blasts 178 </li> 179 <li> 180 0 atypical lymphs 181 </li> 182 <li> 183 <ul> 184 <li> 185 slight L shift 186 </li> 187 </ul> 188 </li> 189 </ul> 190 </li> 191 <li> 192 Plt 490 193 </li> 194 <li> 195 BMP grossly wnl (gluc 202, <a href="https://www.ashclinicalnews.org/viewpoints/editors-corner/illegitimi-epic-non-carborundum-dont-let-epic-bastards-grind/">Cr 196 fine</a>) 197 </li> 198 <li> 199 LFTs fine 200 </li> 201 <li> 202 Trop <0.01 203 </li> 204 <li> 205 urate 10.4 206 </li> 207 <li> 208 phos 5.0 209 </li> 210 <li> 211 LDH 330 212 </li> 213 <li> 214 fibrinogen 355 215 </li> 216 </ul> 217 <h2> 218 Other studies 219 </h2> 220 <ul> 221 <li> 222 EKG wnl 223 </li> 224 <li> 225 CT-PE -ve 226 </li> 227 <li> 228 CT a/p wwo 229 <ul> 230 <li> 231 +10x7cm pelvic mass (central/R adnexum, exerting mass effect on 232 sigmoid colon) 233 </li> 234 <li> 235 spleen ~20cm largest dimension w ?infarcts x2, 236 </li> 237 <li> 238 L internal iliac vein filling defects c/w nonocclusive DVT 239 </li> 240 </ul> 241 </li> 242 <li> 243 PET/CT 244 <ul> 245 <li> 246 splenomegaly with diffusely increased uptake, diffuse FDG uptake of 247 axial and appendicular skeleton, mild uptake of abdominal pelvic lymph 248 nodes, and minimal to mild uptake in the pelvic mass. 249 </li> 250 </ul> 251 </li> 252 </ul> 253 <h2> 254 Further notes on hospital course 255 </h2> 256 <ul> 257 <li> 258 CEA 1.7 (wnl), CA-125 52 (-) 259 </li> 260 <li> 261 urate 9.5 5d later w IVF, given rasburicase 3mg x1 -> urate 262 3.8 263 </li> 264 <li> 265 phos similarly without movement, sevelamer eventually helpful 266 </li> 267 <li> 268 pelvic mass bx: smooth muscle 269 </li> 270 <li> 271 BMBx: hypercellular >90%, no blasts, +trilineage atypica > 272 myeloid, MF-1 fibrosis. 273 </li> 274 <li> 275 JAK2 -ve, BCR/ABL -ve 276 </li> 277 <li> 278 NGS 279 <ul> 280 <li> 281 BRAF 5% (MGUS, MM, hairy cell, hystiocytic/dendritic cell, solid 282 tumors, therapy-related myeloid neoplasms) 283 </li> 284 <li> 285 KRAS 39% (MDS, AML, MDS/MPN inc CMML and JMML) 286 </li> 287 <li> 288 BCOR 49% (?, possibly germline since allele fraction ~50%) 289 </li> 290 <li> 291 BCORL1 48% (ditto) 292 </li> 293 <li> 294 EZH2 93% (?, likely germline w loss of heterozygosity) 295 </li> 296 </ul> 297 </li> 298 </ul> 299 <h2> 300 And then… 301 </h2> 302 <p id="post-excerpt"> 303 Diagnosis is... MDS/MPN/MF NOS. 304 i.e., who knows. 305 </p> 306 <p> 307 Started on hydroxyurea and decitabine, c/b recurrent bacteremia, so 308 currently tx on hold. 309 </p> 310 <hr> 311 <h2> 312 TLS 313 </h2> 314 <p> 315 The big idea, and a few finer points. 316 </p> 317 <p> 318 <a href="https://jamanetwork.com/journals/jamaoncology/fullarticle/2680750"></a> 320 </p> 321 <h3> 322 Cairo-Bishop classification system 323 </h3> 324 <p> 325 (Most of the following derived from <a href="https://www.asn-online.org/education/distancelearning/curricula/onco/Chapter4.pdf">Chapter 326 4</a> of the American Society of Nephrology online <a href="https://www.asn-online.org/education/distancelearning/curricula/onco/">Onco-Nephrology 327 curriculum</a>, which is good and great.) 328 </p> 329 <h3> 330 Laboratory TLS 331 </h3> 332 <p> 333 Definition: Chemotherapy plus the two or more of the following within 334 3d before or 7d after initiation (so doesn’t account for the spontaneous 335 TLS seen in our patient). 336 </p> 337 <p> 338 | Metabolite/Electrolyte | Criterion | | :———————– | 339 :––––––––––––––––––––: | | Uric Acid | >=8 mg/dL or 25% increase from 340 baseline | | Potassium | >=6mEq/L or 25% increase from baseline | | 341 Phosphorus | >=4.5mg/dL or 25% increase from baseline | | Calcium | 342 25% <em>decrease</em> from baseline | 343 </p> 344 <p> 345 The “25% increase/decrease” part is contested, as it may not be 346 clinically meaningful if the value stays within the normal range. 347 </p> 348 <h3> 349 Clinical TLS 350 </h3> 351 <p> 352 | Laboratory TLS and one or more of | | :–––––––––––––––– | | 353 creatinine >= 1.5 ULN (Note: just use AKI criteria) | | cardiac 354 arrhythmia or sudden death | | seizure | 355 </p> 356 <ul> 357 <li> 358 risk assessment 359 </li> 360 </ul> 361 <h3> 362 Treating TLS 363 </h3> 364 <p> 365 IVF, electrolytes, rasburicase. 366 </p> 367 <p> 368 Rasburicase is the subject of a recent “Things We Do for No 369 Reason.” 370 </p> 371 <p> 372 <a href="https://www.journalofhospitalmedicine.com/jhospmed/article/241443/hospital-medicine/things-we-do-no-reasontm-rasburicase-adult-patients-tumor">Pay-walled 373 article</a>, <a href="https://cdn.mdedge.com/files/s3fs-public/JHM01607424.PDF">PDF made 374 available by the authors</a> 375 </p> 376 <p> 377 TL;DR: the evidence is thin, but could be reasonable to 378 </p> 379 <ul> 380 <li> 381 ppx w IVF and allopurinol for low-med risk, 382 </li> 383 <li> 384 use single 3mg dose rasburicase as ppx in high-risk disease (don’t 385 use weight-based dosing), 386 </li> 387 <li> 388 tx active TLS (laboratory or clinical) with aggressive fluid 389 resuscitation and electrolyte mgmt, possibly single 3mg dose. 390 </li> 391 </ul> 392 <p> 393 Hard outcomes in support of rasburicase are generally lacking, e.g. 394 consistently reducing renal injury, renal failure, length of stay. 395 </p> 396 <p> 397 It also seems like the classification criteria need revamping, with a 398 larger N. It’s been a while. However, like redefining fever, it’s 399 difficult to get a clean slate, because we act on the established 400 criteria so aggressively. 401 </p> 402 <hr> 403 <h2> 404 MDS/MPN overlap syndromes 405 </h2> 406 <p> 407 Not much to say here, except that the dx is not always clear-cut, 408 even with BMBx and NGS data, so the clinical picture matters, and 409 sometimes we have to shoot in the dark. 410 </p> 411 <hr> 412 <p> 413 Last updated: 2021-08-22 414 </p> 415 </main> 416 <div id="footnotes"></div> 417 <footer></footer> 418 </div> 419 </body> 420 </html>