Heme 13 – Basics of Leukemia

Before we dive into AML,ALL, CML, CLL, LAD and any other lymphoid neoplasms, we should know about the basics.

Join us on the Common Rounds to learn some foundation knowledge on leukemia.

The Underbelly of Surgery

I had the opportunity to listen to a very interesting and eye opening podcast from Radio National’s Background Briefing  about the state of cosmetic surgery and ethical issues relating to the appropriate qualifications of some of the practitioners providing these services.

The talk raises some really interesting ethical conundrums that are slowly being addressed by the medical profession…but is this enough? Have a listen and let us know what you think!

Click on the link for the article and audio of the investigative journalism: when a surgeon is not a surgeon

 

Bad Pharma

A short post today, as medical students and future doctors we will hold a special place in society. We will be a point of contact between patients and the healthcare system. A system that flirts with both the public and private sector.

Several months ago I had the opportunity to read Bad Pharma by Dr Ben Goldacre. It was a really eye opening book about the role of the pharmaceutical industry an its influence on the practice of medicine. It is undeniable that without a viable pharmaceutical industry our arsenal of pharmacotherapy will be highly limited. However, the relationship we will have with this industry must be politely cautious and not digress from the path of critical thought. It is very easy to forget this when being dined, swooned and seduced by the industry. Thankfully our human fragility is noted and there are more legislative barriers in place (in Australia) to prevent less than professional relationships with the pharmaceutical industry.

Here is a really great TED talk by Dr Ben Goldacre

Communicating or Not?

I’ve been pondering the approaches to good communication by health professionals. We know that good communication is fundamental to delivery of care to our patients. But what defines this:

  • Language style: I think it is imperative for our language style to be age appropriate and take into account our patients level of education, cultural background and understanding about their own health status. I’ve often had to significantly change my communication style, word usage and sentence structure to suite our indigenous patients that I worked with prior to entering medical.
  • Active listening: An important component of communication is active listening, which takes into account our own body language, assessing the contents of the patients conversation, their body language, belief system and culture. These are important for indigenous patients where cultural difference can lead to a break down in communication. I’m still working on this point.
  • Provision of information: This relates to the first point and it should be simple, clear and direct. We must avoid our moral values and beliefs from interfering with the extent and breadth of information provided to patients. More importantly we should allow the patient to draw their own conclusions based upon life circumstances.
  • Questions: Our patients should be given ample opportunity to ask questions, clarifications and validations of key facts presented. This ensures that both parties agree and understand the facts presented during the conversation
  • Summarise: Prior to ending the conversation we should summarise the information presented and allow opportunity for the patient to ask questions. Furthermore, we must make ourself available for further discussion if the need arises.

Also check out the seven daily sins of speaking

HS

Tests in clotting disorders

The following are some tests ordered when assessing/diagnosing some clotting diseases.

Platelet tests:

A normal platelet count would yield ~ 150 – 400 x 10^9 /L platelets.

Bleeding time (BT) evaluates the platelet function up to the formation of the temporary platelet thrombus (primary hemostasis). A normal bleeding time is around 2 – 7 mins.

Platelet aggregation tests look at the aggregation response in response to regents such as ADP, adrenaline, collagen and ristocetin (induces platelet aggregation).

Tests for von Willebrand  factor (vWF) include ristocetin cofactor activity or vWF antigen assays. Ristocetin cofactor activity evaluates the function of vWF, where as the assays measures the quantity of vWF present in the serum.

Coagulation tests:

Prothrombin time (PT) assesses the extrinsic and common coagulation pathway. It involves factors VII, X, II and I. A normal PT is around 11 to 15 seconds. PT is commonly used to evaluate liver synthetic function, detect factor VII deficiency or monitor patients who are on warfarin.

The International normalized ratio (INR) is a value derived from PT, used as a standard to monitor patients on warfarin. While varying with the condition, a normal INR target for warfarin patients is between 2-3.

The activated Partial Thromboplastin Time (aPTT) evaluates the intrinsic and common pathway. The factors involved are XII, XI, IX, VIII, X,V,II,I. The normal reference interval would be 25-40 seconds. It is most commonly used to monitor heparin anticoagulation therapy. It’s also used to detect factor deficiencies in the intrinsic coagulation system.

Fibrinolytic sytem tests:

Fibrin(ogen) degradation products (FDP) are used to detect fragments associated with the plasmin degradation of fibrinogen or insoluble fibrin in the fibrin clots.

D-Dimer assays are specific tests that determine degradation of cross-linked fibrin monomers only. It does not detect fibrinogen degradation products as they do not form cross-links. It’s of particular clinical use when assessing deep vein thrombosis, pulmonary thromboembolisms and disseminated intravascular coagulation.

Reference:

Goljan Rapid review Pathology 4th edition

The Checklist

I’ve recently had the pleasure of reading the Checklist Manifesto by Atul Gawande, a truly remarkable figure in public health and surgery. His brave and candid appraisal of the state of healthcare with a particular emphasis on surgery was simultaneously refreshing and terrifying.

His confessions about the enormous challenges associated with delivery of care, complexity of knowledge and heterogeneity of patients as well as uncooperative health professional attitudes conjures a healthcare system prone to error and adverse patient outcome. Nevertheless, Dr Gawande courageously confronts this engrossing problem through an amazingly simple solution…The Checklist.

His implementation of surgical checklists in diverse hospital settings and localities has demonstrated the simplicity, elegance and cost-effectiveness of this tool. His checklist has resulted in significant improvements in health outcomes with results published in premiere journals including the New England Journal of Medicine. More importantly the tool has saved countless lives, which is ultimately its greatest achievement. It is evidence-based practice at the apogee of medical care.

Here is also a TED Talk  about some of the points raised: