Hematology

I. INTRO

Welcome To the Hematology Elective!

We expect you to be present Monday through Friday while you are assigned to our service. If you have an unforeseen problem arise, you must contact the Hematology Attending Physician to get permission for your absence. If you are pulled from the elective to cover another service, you must notify the Hematology Attending, Fellow, and Nicole Reed, the Division Admin. Assist. (Ext. 4137). Please make sure that Nicole has your correct beeper number, so that we can contact you during the day if necessary.

Consults

Hematology is a consult service in our hospital. You are encouraged to see consults by yourself and to follow as many patients as possible with the fellow on the service.

1. You should review each patient with the fellow as soon as you have seen them so the degree of urgency can be assessed.

2. You should leave a brief note in the progress note section of the chart saying that the patient has been seen and will be presented to the Attending the following day.

3. Bring your Attending a Consult Continuation Page or an index card stamped carefully with the patient’s card. Check to see which one they prefer. The information on the stamp may be used for billing purposes so make sure that it is complete and legible.

4. Using the “Ten Commandments for Effective Consultations” as a guide, complete the consult form prior to the presentation on rounds and have the Attending sign it or attach their note after the patient is seen. A copy of the completed consult should then be filed in the Consult Notebook in the Fellows’ Room at the Monte I Office. An example of a consultation check list is included in the packet.

5. The Attending will make rounds with you 3-5 times a week, depending on the number of consults.

Clinics

You are expected to attend the Montefiore Hematology Clinic each week. The Montefiore Clinic is held in DTC 460 at 12:30 PM on Wednesday. BE PROMPT. Please notify Dr. Friedman if you have a conflict for either of these clinics.

Conferences

We have included a monthly conference schedule in your packet. These are the conferences for fellows and residents. You are expected to attend these conferences as part of your elective. In addition, residents meet separately with Dr. Friedman at 8AM on Wednesday for a case-based conference. This resident conference will begin promptly at 8AM.

Teaching Materials

1. Morphology: Slide banks are available online (see below). Recent article on Blood Smear Diagnosis (NEJM335, 2005) Included in the packet.

2. Hematology Library: We have copies of the major Hematology, Medicine, and Oncology Textbooks in the library in the Fellows: Room. Please use these books in the room and copy sections that you may want to read at home. THESE BOOKS MAY NOT BE REMOVED FROM THE ROOM AND MUST BE PUT AWAY IN THE CABINET AT THE END OF EACH DAY.

3. Hematology Curriculum for Medicine Residents: We have enclosed a copy of the 2006 revision of this West Campus Curriculum for you to use during this rotation. It was adapted from national guidelines and should serve as a guide for your reading studying during your residency.

We are interested in making this an excellent learning experience for you. Please feel free to contact Dr. Friedman if you have any questions or problems during the month

Dr. Ellen Friedman : 920-4137

Beeper: 917-457-5706


HEMATOLOGY STUDY CASES

We will meet weekly while you are on the Hematology elective to discuss study cases.

We will meet at 8AM each Wednesday in the Monte I Hematology Conference Room. You will be given a Case Study to read, analyze, and “care for” several days before in conference. These are actual patients who have been referred to the Hematology Consult Service for evaluation. You are expected to carefully read the case and define the hematologic problem. You should then read “in-depth” in order to establish a differential diagnosis and the probability of each diagnosis. You will also decide what morphologic changes would be present on the peripheral smear for each of your possible diagnoses. Finally, you should plan a diagnostic evaluation, carefully considering the sensitivity and specificity of the tests you will order.

This is your opportunity to learn how to approach the diagnosis of hematologic problems. You will be expected to be able to discuss how you arrived at your list of possible diagnoses and to discuss some of the pathophysiology and treatment of these diseases.

These conferences will begin promptly at 8Am. Please call me in advance at 920-7388 if you know that you will not be able to attend. The teaching cases are included in the packet.

HEMATOLOGY MORPHOLOGY

1. American Society Of Hematology has an image bank at www.ashimagebank.org/collections/ and Duke University also has an image bank at http://image.bloodline.net. Please avail yourself of these study guides.

2. Dr. Goldstein conducts morphology sessions weekly 8:30 - 9:30 Thursday morning.

3. Attending Rounds include peripheral smear and Bone Marrow morphology.

4. Clinic has a microscope for abnormal blood smear review at the time of the consultation.


II. GOALS

To provide training and experience at a sufficient level for the Internal Medicine trainee to acquire competency in basic Hematology. Basic skills pertain to the recognition, diagnosis, and management of disorders involving the blood, bone marrow, lymph nodes and spleen. Trainees will learn to recognize situations in which subspecialty consultation is appropriate.

To instruct the Internal Medicine trainees in the basic physiologic and pathophysiologic mechanisms of hematopoiesis, functional aspects of blood cells, hemostasis, the immune system, and to provide updates on ongoing advances in Hematology as elucidated in the basic science literature.

The hematology elective is a block duration of four (4) weeks and involves participation in the in-patient consult service and out-patient continuity clinic once weekly. It includes a daily series of case based conferences and morphology rounds.

II. HEMATOLOGY CURRICULUM OBJECTIVES

5. Principles, Physiology and Basic Sciences

1. Fundamental concepts of cellar and molecular biology, including the importance of growth factors in cell proliferation.

2. Hematopoiesis and the bone marrow, including morphology and physiology of blood and blood-forming organs.

3. Hemoglobin synthesis, structure, and function.

4. Evolution of clonal disease of hematopoietic cells and lymph nodes concentrating on chronic leukemias, myeloproliferative disorders, multiple myeloma, and low-grade lymphomas.

5. Hemostasis and thrombosis, including functional aspects of platelets, blood vessels, coagulation pathways, and fibrinolysis.

6. Transfusion medicine and component replacement therapy; Immunohematology as it relates to primary care medicine and transfusion reactions.

2. Practice Skills Unique To Hematology

1. History

· Bleeding

· Genetic aspects of hematologic disease

· Functional capacity or quality of life

· Environmental factors, e.g. diet and occupation

2. Physical

· Skin and mucous membranes for petechiae/purpura, nutritional state

· Lymph note palpation

· Examination of liver and spleen

· Fundoscopic exam

3. Specific Tests/Procedures: Use and Interpretation

· CBC, peripheral smear, reticulocyte count (RPI).

· Nutritional assessment of anemia: serum iron transferrin, ferrintin, B12, folate, homocyteine, methyl malonic acid, Schilling test.

· Assessment of hemolysis: haptoglobin, Coomb’s testing, urinary hemosiderin, G6PD, osmotic fragility, cold agglutinins.

· Hemoglobinopathies: sickle prep, hemoglobin electrophoresis (cellulose, acid, isoelectric), quantitative hemoglobin A2 and F

· Serum and urine protein electrophoresis, immunofixation electrophoresis, quantitative immunoglobulins, Bence-Jones proteins.

· PT/PTT, fibrinogen, fibrin split products, D-dimer, mixing tests, thrombin time, factor assays.

· Bleeding time, platelet aggregation studies, Heparin-PF4 antibodies

· Antithrombin III, Protein C, protein S, factor V R506Q (Leiden), PT20210, lupus anticoagulant, anticardiolipin antibodies.

· Serum erythropoietin.

· Leukocyte alkaline phosphatase (LAP).

· Blood compatibility; transfusion reaction work-up.

· Indications for bone marrow aspiration and biopsy.

4. Preventive Care

· Nutritional requirements for hematopoiesis

· Monitoring patients on anticoagulation

5. Patient Education

· Living with a chronic disease, e.g. sickle cell, hemophilia

· Medication administration and complications

6. Attitudes/Value

· Effects of race and age on hematologic parameters

· Needs of patients living with chronic pain

· Risks of transfusion

3. The Approach To Presenting Complaints/Problems

1. Symptoms focused: plethora, pallor, orthostasis, recurrent infections, bleeding, thrombosis, lymphadenopathy, splenomegaly.

2. Laboratory focused: pancytopenia, specific cytopenia, erythrocytosis, leukocytosis, thrombocytosis, clotting test abnormalities, hyperviscosity.

3. Disease focused: e.g. sickle cell disease, transfusion reaction, ITP/TTP

D. Specific Diagnoses In Hematology

1. Disease of red blood cells

· Aplastic anemia

· Nutritional anemias

· Anemia of chronic disease

· Hemolytic anemia

· Sickle cell and other hemoglobinopathies

· Erythrocytosis/Polycythemia

2. Disease Of White Blood Cells

· Neutropenia

· Leukemoid reaction

3. Neoplastic/premalignant disorders

· Myelodysplastic syndrome

· Myeloproliferative disorders

· Chronic Leukemias

· Lymphomas

· Monoclonal gammopathy of uncertain significance (MGUS)

· Mutiple myeloma

· Waldenstrom’s macroglobulinemia

· PNH

4. Hemostatic and thrombotic disorder

· Hemophilia A and B

· vonWillebrand’s Disease

· Circulating anticoagulants: antiphospholipid syndrome

· ITP

· DIC/TTP/HUS

· Hypercoagulable states: primary and secondary

5. Hematologic Complications of Systemic Conditions/Disorders

· AIDS

· Connective tissue diseases

· Alcohol related

· Organ failure, e.g. cirrhosis, renal insuffieciency

· Sepsis

· Pregnancy

6. Hematologic Complications of Medical Therapies

· Drug toxicities: thrombocytopenia, leukopenia, eosinophilia, hemolysis

· Effects of thrombolytics

5. Emergencies In Hematology

1. Pancytopenia

1. Severe anemia

3. Blast crisis/leukostasis

4. Superior vena cava syndrome

5. Hyperviscosity

6. Severe thrombocytopenia

7. DIC/HUS/TTP

8. Bleeding

9. Transfusion reactions

F. Treatment Modalities

1. Anticoagulation

· Heparin, low molecular weight heparins

· Coumadin

· Hirudin

· Antiplatelet agents

· Thrombolytic therapy

2. Use of Blood components

· PRBC, FFP, platelets, factors, cryoprecipitate

· Therapeutic phlebotomy and apheresis

3. Use of growth factors

· Erythropoietin

· G-CSF, GM-CSF

4. Selected antineoplastic agents

· chlorambucil, busulfan, hydrocyurea,

· vincristine, cyclosphosphamide, fludarabine

· alpha-Interferon

· Anagrelide

· Rituxan

5. Pheresis

· Plasmapheresis, exchange transfusion

6. Other medical therapies

· Prednisone

· IV gamma globulin, anti -RHD

· DDAVP

G. Technical Skills, Including Procedures

1. Peripheral blood smear: preparation and interpretation

2. Bone marrow aspiration and biopsy: indications, complications, method

3. Therapeutic phlebotomy

III. COMPETENCY BASED OBJECTIVES

3. Patient Care

Recognize hematologic disease entities and how they may present; recognize the indications for hematologic procedures; learn the indications for treatment.

Venue: In-patient Consult Service, Emergency Room consultation, Out-patient consultation.

Assessment: Monthly evaluation.

4. Medical Knowledge

Use of medical literature and acquisition of new information related to individual cases. Ability to teach that new information to peers.

Venue: Case conference didactic sessions, attending rounds, preceptor sessions in clinic.

Assessment: Monthly evaluation.

5. Professionalism

Establish patient rapport including winning their confidence, establish staff rapport winning their respect, working closely with peers, fellows and attending to promote good patient care, know limitations, be responsible to commitments.

Venue: In-patient Consult Service, Emergency Room consults, Clinic consults.

Assessment: Monthly evaluation.

D. Interpersonal and Communication Skills

Be able to communicate both in writing and verbally with house-staff and attendings, the issues related to an individual patient’s care. Be able to address patient’s questions and needs.

Venue: In-patient Consult Service, Emergency Room consults, Clinic consults.

Assessment: Monthly evaluation.

5. Practice Base Learning

Recognize limits of knowledge and know how to expand them; apply information learned from resources to a new patient, know how to alter previous plans if the treatment is not effective, learn from patients’ outcomes.

Venue: All consultations, attending and preceptor rounds.

Assessment: Monthly evaluation.

F. Systems Based Practice

Advocate for patients in cumbersome conditions need as procurement of expensive medications; explore methods to facilitate the administration of non-oral medications; learn how to use ancillary services to facilitate delivery of needed services.

Venue: In-patient and Out-patient consultation.

Assessment: Monthly evaluation


IV. TRAINING SITES

A. General Medicine Wards

B. General Medicine Continuity Clinic

C. Medical Consult Service: Moses and Weiler

D. Hematology elective

1. Consult Service

2. Hematology Clinic: Montefiore Medical Center Hematology Clinic

3. Hematology Laboratory

E. Emergency Room

F. Private Offices

V. TEACHING CONFERENCES/ACTIVITIES

A. Departmental Housestaff Conferences

1. Noon conferences: conferences addressing the core curriculum are given by Hematology faculty throughout the academic year

2. Morning report: selected cases are discussed by experts in the field

· Ward Service Morning Report

· Primary Care Morning Report

· Ambulatory Care Block Rotation Morning Report

3. Medical Grand Rounds

4. Board Review

B. Subspecialty Conferences (during Hematology elective)

1. Divisional Conferences (participants: faculty, fellows, residents, students)

· Interesting Case Conference (weekly)

· Hematology grand Rounds (weekly)

2. Trainee Conferences (participants: fellows, residents, students, preceptor)

· Coagulation Conference (every 2 weeks)

· Red Cell Conference (every 2 weeks)

· Morphology Rounds (weekly)

· Transfusion Conference (every 2 weeks)

· Journal Club (every 2 weeks)

· Sickle Cell Rounds (weekly)

· Fellow and Faculty Interesting Case (weekly)

· Thrombosis and Hemostasis Rounds (weekly)

3. Resident Conferences


VI. RECOMMENDED REFERENCES

Beutler, Ernest, Lichtman, Marshall A., Coller, Barry S., Kipps, Thomas J. Williams Hematology. McGraw-Hill, Inc. New York, 1995 (5th Ed).

Handin, Robert I., Lux, Samuel E., Stossel, Thomas P. Blood: Principles and Practice of Hematology. J.P. Lippincott Company. Philadelphia, 1995.

Hoffman, Ronald, Benz, Edward J. Jr., Shattil, Sanford J., Furie, Bruce, Cohen, Harvey J., Silverstein, Leslie E. Hematology: Basic Principles and Practice. Churchill Livingstone. New York, 1999 (3rd Ed).

Lee, G. Richard, Bithell, Thomas C., Foerster, John, Atens, John W., Lukens, John N. Wintrobe’s Clinical Hematology. Lea and Febiger, Philadelphia, 1999 (10th Ed.)