Haematology CASES PLI – 5 - PowerPoint Presentation

Slide1

HaematologyCASES PLI – 5th February 2020

Kieran BrownGP – Devonshire Green and Hanover Medical CentreLynsey FredrickGP Registrar - Chesterfield and Derbyshire GP Training Scheme

Slide2

AimsHow’s it going?

What makes a good CASES referral?Top 10 tips from CASES Explore a topic in more detailHow can we make Haematology CASES more useful for you and our patients?

Slide3

Themes and TrendsKieran Brown

Slide4

What you refer to us…

The top five:Clotting disorders – 16%Polycythaemia – 14%Anaemia – 13%

Immunoglobulinaemia – 9%

Anticoagulant - 8%

Slide5

What you refer to us…

Slide6

The problem of “Other”

Slide7

What we do with your referrals…

Slide8

What we do with your referrals…

Just send them on to haematology! – 72%Send them back with advice – 22%Send them back asking for more info – 3%Send back for another specialty – 2%

Send back for 2ww – 1%

Slide9

What we do with your referrals…

Slide10

Development opportunities

Slide11

Development opportunities

Slide12

No more pie charts…

Any surprises?

Slide13

Help us to help you

1 – Provide us with results

Slide14

Help us to help you

2 – send PMH, meds, results as an attachment

Slide15

Help us to help you

3 – Use the PRESS Portal Guidelineshttps://www.sheffieldccgportal.co.uk/cases/haematology

Slide16

Slide17

Haematology Top 10 TipsLynsey Fredrick

Slide18

ObjectivesFeel a bit more confident in managing abnormal FBC results in otherwise well patients

Consider the question/concern/end point of referralsAm I worried about a haematological condition? e.g. bleeding/clotting risk or haematological malignancy?

Slide19

Or am I worried about…

Managing uncertainty (What COULD it be? SHOULD I be worried about it?!)Monitoring (how often should I recheck?

FOREVER?!)

When

to refer

(when is

it TOO

high/low? Why

?!)

Investigating

(

how do I balance the

worry

of missing

something with the risks of over-investigation?)

MY BRAIN

Slide20

ObjectivesFeel a bit more

confident in managing abnormal FBC results in otherwise well patientsConsider the question/concern/end point of referral

Am I worried about a haematological condition?

e

.g. bleeding/clotting risk or

h

aematological malignancy?

Slide21

The caveat to all things Haematology…

Patients with: -

Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide22

In most other cases consider:

Repeating test in 4-6 weeks with blood film

Monitoring at

3 months, then

6 monthly then annually…non-progression

is reassuring

Slide23

1. Hb

= HighDefinition: Hb

>

♀147, ♂

166

Question: ?Haem cause

eg

polycythaemia ?Haem problem

eg

clotting risk

Raised

haematocrit

>♀0.48, ♂0.52

Have

confidence in trying to normalise the

sample

Hydration

. Tourniquet free! Smoking. Alcohol.

Anabolic

steroids. Apnoea. Thiazides

etc

…

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide24

2. Hb

= LowDefinition:

Hb

<♀11.0, ♂13.5

Question: ?Haem cause of non-IDA ?Managing IDA

Trial

oral iron if

ferritin normal

Consider

iron

studies

If we recommend

eg

reticulocytes, LDH etc…

you don’t have to interpret abnormal results…

B

ut be reassured by normal results!

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide25

3. MCV = High

Definition: MCV >

98

Question: ?Haem cause of

macrocytosis

eg

MDS

There

is little of haematological concern UNLESS other FBC abnormalities

present

Perform

immunoglobulins and

reticulocytes

Refer

if persistently and inexplicably >104

Many

may only need 6-12 monthly monitoring

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide26

4. Platelets = High

Definition: Platelets

>

400

Question

: ?Haem cause

eg

ET, PRV, MF, MDS, CML ?Haem

problem

eg

c

lotting risk

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide27

However any of the following questions are also acceptable…Why me?!

Who ordered this test?!Can I bounce it / ignore it / make it not my problem?!Do they have cancer? I didn’t think they had cancer…Should I have thought they had cancer?Do I have to look for cancer in this otherwise perfectly well 45 year old who had an FBC because their left little fingernail was a bit itchy 6 months ago?! Can I ask a Haematologist?!

Slide28

4. Platelets = High

Definition: Platelets >

400

Question: ?Haem cause

eg

ET, PRV, MF, MDS, CML ?Haem problem

eg

clotting risk

Think

about iron deficiency

anaemia

Think about metabolic syndrome

Think

about

CXR

If

platelets >

400

but <

600

consider 6 monthly

monitoring in

preference to referral

but

see

slides later for

more…

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide29

5. Platelets = Low

Definition: Platelets

<

150

Question: ?Haem cause

eg

ITP, MDS, aplastic anaemia ?Haem problem

eg

bleeding risk

Most surgery can

be performed with platelets >

50!

Liver disease and alcohol

– strong contenders.

And PPIs!

Refer

if persistently,

inexplicably

less than

80

Don’t

worry too much if above this and stable without other cell line abnormalities

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide30

6. White cells = High

Definition: Total WCC >9.5

Question: ?Haem cause

eg

leukaemia, lymphoma or MPD

Can refer

if total WCC >

20, however…

i

t’s the individual counts that count!

Eosinophilia =

>0.5

Usually reactive to something rather than haematological

cause – asthma, allergens, AI conditions

Refer if

inexplicably >2

for >6

weeks

Monocytosis

= >1

Similar causes to neutrophilia, refer

if chronically >1

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide31

6. White cells = High

Neutrophilia = >6.5

Screen

for

infection and inflammation

Consider metabolic syndrome as a cause

Refer if >

15

Lymphocytosis =

>

3

Yes it may be

CLL, especially if >7,

but can grumble for years and don’t need to be seen until >10

Screen for infection and inflammation

Consider metabolic syndrome as a cause

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide32

7. White cells = Low

Definition: Total WCC <3.5

Question: ?Haem cause

eg

aplastic anaemia, MDS,

hypersplenism

, leukaemia

Lymphopenia

= <

1

Usually

transient. Repeat!

Common in elderly

Viral infections, consider BBV

screen

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide33

7. White cells = Low

Neutropenia = <1.7

(or <1 depending on ethnicity

)

Infection risk increases greatly <0.5

PPIs!

B12/folate deficiency

Autoimmune disease and viral infections

Repeat

at 4-6/52

Refer if inexplicably remains 1-1.5

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide34

Patients with:

- Other FBC abnormalities- Lymphadenopathy or Splenomegaly- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Question for Haem: ?Myeloma/MGUS

Only

interested in raised immunoglobulins if there’s an associated

paraprotein

band

Refer urgently if the patient has

Polyclonal

gammopathy

isn’t

worrying from

a haematology point of

view

Usually

a non-specific immune reaction

8

. Immunoglobulins = High

Slide35

9. Splenomegaly

Definition: >12,13,14cm???

Question for Haem: ?Leukaemia ?Lymphoma ?Haemolysis ?

Myelofibrosis

Blood film and repeat in 6 months if otherwise well

A wise haematologist once said:

“

3D organ measured in 2D on a blurry image,

no allowances

made for body

habitus

?

…no

wonder

it’s not a useful

measure

.”

Anon, circa 2019

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

=

REFER

Slide36

10. Raised ferritin

Definition: Ferritin > 400Question for Haem: ?Haemochromatosis

Consider reactive causes and liver disease

Re: haemochromatosis -

FHx

,

diabetes, arthritis

But ultimately check

transferrin

saturation

If transferrin raised or concerned, refer

to

Hepatology

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

= REFER

Slide37

Slide38

10. Raised ferritin

Definition: Ferritin > 400Question for Haem: ?Haemochromatosis

Consider reactive causes and liver disease

Re: haemochromatosis -

FHx

,

diabetes, arthritis

But ultimately check

transferrin

saturation

If transferrin raised or concerned, refer

to

Hepatology

Otherwise consider Ix for underlying inflammatory cause

Patients with:

- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of thrombosis

= REFER

Slide39

In otherwise well patients:

Who don’t have:- Other FBC abnormalities

- Lymphadenopathy

or Splenomegaly

- Weight loss, fevers, night

sweats

- History

of

thrombosis

Slide40

In otherwise well patients:

Consider:

- Repeating the test with blood film

- Monitoring at 3 months, then 6 months then annually…

…non-progression is reassuring!

Slide41

ThrombocytosisKieran Brown

Slide42

What is thrombocytosis?

Platelets raised (>2s.d. above the mean)Clonal – caused by a myelodysplastic or myeloproliferative neoplasm

–

a haematological problem – 10-20%

Vs.

Reactive –

response to an inflammatory or neoplastic condition elsewhere, iron deficiency, bleeding

-

our problem? – 80-90%

Slide43

What do our local guidelines say?

Urgent referral if plt > 1000Or 600-1000 with thrombosis, neurological symptoms, or bleedingRoutine referral if

plt

>600 on 2 occasions 4-6 weeks apart

Or 450-600 with splenomegaly, elevated Hb or WCC, thrombosis in past 2 years

Slide44

So what’s the problem?

12 month incidence of cancer higher if raised platelets - approximately 3x riskPoor prognosis for solid organ tumours with associated thrombocytosis

Slide45

Occult Malignancy

LEGO-CLungEndometrialGastricOesophogealColorectalAnd Renal

Slide46

So where do we start?

HistoryExaminationFurther investigationsRepeat FBCBlood filmInflammatory markersFerritin (+/- iron profile)

Slide47

Further investigations

Chest X-ray – LPelvic US if vaginal discharge – E

Direct access OGD if nausea, vomiting, weight loss, reflux or dyspepsia –

GO

FIT test?? (Not in current guidelines) –

C

Renal US? CT???

Slide48

Next steps

AuditManaging anxieties – ours and patientsEvolution of evidence

Slide49

Thank you!

Time for questions and discussion?kieran.brown@doctors.org.uklynseyfredrick@nhs.net