Podcast
Questions and Answers
Which factor has the shortest half-life among the vitamin K-dependent factors?
Which factor has the shortest half-life among the vitamin K-dependent factors?
- Factor VII (correct)
- Factor IX
- Factor II
- Factor X
What is the most common cause of vitamin K deficiency?
What is the most common cause of vitamin K deficiency?
- Exposure to sunlight
- Inadequate oral intake (correct)
- Genetic mutation
- Excessive oral intake
Which patients may require smaller than expected doses of warfarin therapy?
Which patients may require smaller than expected doses of warfarin therapy?
- Patients with normal vitamin K levels
- Patients with excessive vitamin K intake
- Patients with vitamin K toxicity
- Patients with baseline vitamin K deficiency (correct)
What is the treatment of choice for vitamin K deficiency?
What is the treatment of choice for vitamin K deficiency?
Which treatment administration route should be avoided in patients with coagulopathies to prevent hematomas?
Which treatment administration route should be avoided in patients with coagulopathies to prevent hematomas?
What is the mainstay of Thrombotic Thrombocytopenic Purpura (TTP) treatment?
What is the mainstay of Thrombotic Thrombocytopenic Purpura (TTP) treatment?
Which enzyme cleaves von Willebrand factor multimers in the context of TTP?
Which enzyme cleaves von Willebrand factor multimers in the context of TTP?
What establishes the diagnosis of TTP?
What establishes the diagnosis of TTP?
Which manifestations are classic in patients with TTP?
Which manifestations are classic in patients with TTP?
What is the role of immunosuppressive drugs like prednisone or rituximab in TTP treatment?
What is the role of immunosuppressive drugs like prednisone or rituximab in TTP treatment?
What is the effect of Vitamin K administration in TTP patients?
What is the effect of Vitamin K administration in TTP patients?
What predicts the likelihood of finding low ADAMTS13 activity diagnostic for TTP?
What predicts the likelihood of finding low ADAMTS13 activity diagnostic for TTP?
What is the recommended route for administering TTP treatment?
What is the recommended route for administering TTP treatment?
What may be present in addition to thrombocytopenia and microangiopathic hemolytic anemia in TTP diagnosis?
What may be present in addition to thrombocytopenia and microangiopathic hemolytic anemia in TTP diagnosis?
What is the effect of reduced ADAMTS13 activity in TTP?
What is the effect of reduced ADAMTS13 activity in TTP?
When should Thrombotic Thrombocytopenic Purpura (TTP) be treated?
When should Thrombotic Thrombocytopenic Purpura (TTP) be treated?
What is the primary cause of coagulopathy in liver disease?
What is the primary cause of coagulopathy in liver disease?
Which test is used for screening coagulation factor deficiencies in liver disease?
Which test is used for screening coagulation factor deficiencies in liver disease?
What is the prevalence of Idiopathic Thrombocytopenia Purpura (ITP)?
What is the prevalence of Idiopathic Thrombocytopenia Purpura (ITP)?
What is the recommended diagnostic approach for ITP?
What is the recommended diagnostic approach for ITP?
What is the primary treatment for liver disease-induced coagulopathy?
What is the primary treatment for liver disease-induced coagulopathy?
What may cause secondary ITP?
What may cause secondary ITP?
What is the gender primarily affected by ITP?
What is the gender primarily affected by ITP?
What is the most reliable test for diagnosing ITP?
What is the most reliable test for diagnosing ITP?
What is the association of severe liver disease with thrombosis?
What is the association of severe liver disease with thrombosis?
What is the effect of liver disease on PT and aPTT?
What is the effect of liver disease on PT and aPTT?
Which factor is particularly affected by impaired production in liver disease-induced coagulopathy?
Which factor is particularly affected by impaired production in liver disease-induced coagulopathy?
What is the primary cause of coagulopathy in liver disease?
What is the primary cause of coagulopathy in liver disease?
What is the primary cause of coagulopathy in liver disease?
What is the primary cause of coagulopathy in liver disease?
Which test is disproportionately longer in patients with liver disease-induced coagulopathy?
Which test is disproportionately longer in patients with liver disease-induced coagulopathy?
What is the prevalence of Idiopathic Thrombocytopenia Purpura (ITP)?
What is the prevalence of Idiopathic Thrombocytopenia Purpura (ITP)?
What is the recommended treatment for liver disease-induced coagulopathy?
What is the recommended treatment for liver disease-induced coagulopathy?
What is the primary age group affected by Idiopathic Thrombocytopenia Purpura (ITP)?
What is the primary age group affected by Idiopathic Thrombocytopenia Purpura (ITP)?
What is the main screening test for coagulation factor deficiencies in liver disease?
What is the main screening test for coagulation factor deficiencies in liver disease?
What is the most reliable diagnostic evidence for Idiopathic Thrombocytopenia Purpura (ITP)?
What is the most reliable diagnostic evidence for Idiopathic Thrombocytopenia Purpura (ITP)?
What is the effect of severe liver disease on fibrinolysis and thrombosis?
What is the effect of severe liver disease on fibrinolysis and thrombosis?
What is the primary factor affected in liver disease-induced coagulopathy?
What is the primary factor affected in liver disease-induced coagulopathy?
In which patients is coagulopathy primarily seen in liver disease?
In which patients is coagulopathy primarily seen in liver disease?
What is the recommended treatment for severe liver disease-induced coagulopathy?
What is the recommended treatment for severe liver disease-induced coagulopathy?
When is a bone marrow examination required for diagnosing ITP?
When is a bone marrow examination required for diagnosing ITP?
What is the scoring system for Heparin-induced thrombocytopenia (HIT)?
What is the scoring system for Heparin-induced thrombocytopenia (HIT)?
What percentage of patients with low pretest probability of HIT have HIT antibodies?
What percentage of patients with low pretest probability of HIT have HIT antibodies?
What should be done if HIT is suspected?
What should be done if HIT is suspected?
What is the mainstay of treatment for Thrombotic Thrombocytopenic Purpura (TTP)?
What is the mainstay of treatment for Thrombotic Thrombocytopenic Purpura (TTP)?
What are the conditions that can cause Disseminated Intravascular Coagulation (DIC)?
What are the conditions that can cause Disseminated Intravascular Coagulation (DIC)?
What are the characteristics of acute DIC?
What are the characteristics of acute DIC?
What do D-dimer and fibrin degradation products reflect in DIC?
What do D-dimer and fibrin degradation products reflect in DIC?
What should testing for DIC include?
What should testing for DIC include?
What is the recommended duration of anticoagulation for HIT?
What is the recommended duration of anticoagulation for HIT?
When can patients with a history of HIT be safely reexposed to heparin?
When can patients with a history of HIT be safely reexposed to heparin?
What is the recommended initial treatment for all patients with thrombocytopenia?
What is the recommended initial treatment for all patients with thrombocytopenia?
In refractory cases of thrombocytopenia, which of the following immunosuppressants may be used?
In refractory cases of thrombocytopenia, which of the following immunosuppressants may be used?
What is the primary cause of Heparin-Induced Thrombocytopenia (HIT)?
What is the primary cause of Heparin-Induced Thrombocytopenia (HIT)?
When does HIT typically manifest after starting any kind of heparin?
When does HIT typically manifest after starting any kind of heparin?
What percentage of patients who have HIT develop thrombosis?
What percentage of patients who have HIT develop thrombosis?
What is the most sensitive, readily available screening test for HIT?
What is the most sensitive, readily available screening test for HIT?
What does a lower platelet count than usual suggest in HIT?
What does a lower platelet count than usual suggest in HIT?
What is the primary treatment for all patients with thrombocytopenia?
What is the primary treatment for all patients with thrombocytopenia?
What may be used for treatment of refractory cases of thrombocytopenia?
What may be used for treatment of refractory cases of thrombocytopenia?
Study Notes
Thrombotic Thrombocytopenic Purpura (TTP) - Key Points
- Parenteral treatment should be administered subcutaneously or intravenously, not intramuscularly
- Intramuscular injections should be avoided in patients with coagulopathies to prevent hematomas
- Vitamin K administration takes 18–24 hours to have effect; fresh frozen plasma or prothrombin complex concentrate may be required for bleeding patients
- Patients with TTP exhibit systemic illness with classic manifestations including thrombocytopenia, microangiopathic hemolytic anemia, neurologic abnormalities, fever, and acute kidney injury
- TTP diagnosis requires thrombocytopenia and microangiopathic hemolytic anemia; neurologic abnormalities and acute kidney injury may also be present
- ADAMTS13 enzyme cleaves von Willebrand factor multimers; its deficiency leads to platelet aggregation and microcirculation clumping
- Reduced ADAMTS13 activity and positive anti-ADAMTS13 antibody test establish the diagnosis of TTP
- The "PLASMIC" score predicts the likelihood of finding low ADAMTS13 activity diagnostic for TTP
- Plasma exchange is the mainstay of TTP treatment, improving survival rates from 90% mortality to 90% survival
- Immunosuppressive drugs like prednisone or rituximab are used to reduce the production of anti-ADAMTS13 antibody
- Thrombotic Thrombocytopenic Purpura (TTP) should be treated when suspected, and a definitive diagnosis is not necessary to initiate treatment
- Liver disease-induced coagulopathy may present asymptomatically or incidentally on coagulation laboratory studies
Heparin-Induced Thrombocytopenia and Disseminated Intravascular Coagulation
- Heparin-induced thrombocytopenia (HIT) scoring system: 0-3 points indicate low probability, 4-5 points indicate intermediate probability, and 6-8 points indicate high probability.
- HIT antibodies were found in 0.9% of patients with low pretest probability, 11.4% in those with intermediate scores, and 34% in those with high scores.
- Heparin must be discontinued if HIT is suspected, and an alternative anticoagulant such as argatroban or fondaparinux should be started.
- Low-molecular-weight heparin should not be substituted, and warfarin should not be used until platelet count recovers.
- Anticoagulation should continue for 2-3 months.
- Patients with a history of HIT can be safely reexposed to heparin after a year, if necessary.
- Disseminated Intravascular Coagulation (DIC) presents as uncontrolled spontaneous diffuse bleeding in patients with severe illness.
- Conditions that cause DIC include trauma, advanced adenocarcinomas, obstetric crises, and acute promyelocytic leukemia.
- In some cases of DIC, clotting manifestations may predominate, leading to recurrent thrombosis without bleeding.
- Acute DIC is characterized by thrombocytopenia, prolongation of PT/INR and aPTT, reduction of plasma fibrinogen level, and increases in D-dimer and fibrin degradation products.
- D-dimer and FDP reflect fibrinolytic activity, and fibrinogen levels below 100 mg/dL may correlate with bleeding risk in DIC.
- Testing for DIC should include platelet count, PT/INR, aPTT, fibrinogen, and D-dimer.
Treatment of Thrombocytopenia and Heparin-Induced Thrombocytopenia
- Serologic studies are indicated if SLE, hepatitis C, or HIV infection is suspected.
- High-dose corticosteroid, such as prednisone or dexamethasone, is the initial treatment for all patients with thrombocytopenia.
- Patients who do not respond to corticosteroids or whose thrombocytopenia recurs when the corticosteroids are stopped may undergo splenectomy.
- In refractory cases of thrombocytopenia, other immunosuppressants may be used, such as rituximab, azathioprine, or cyclophosphamide.
- Thrombopoietin analogues such as romiplostim and eltrombopag have become more widely used for treatment of refractory cases of thrombocytopenia.
- Heparin-Induced Thrombocytopenia (HIT) is caused by the development of an antibody directed against a heparin-platelet factor 4 complex.
- HIT develops in about 5% of patients who receive heparin, with surgical patients at higher risk.
- HIT manifests between 5 and 10 days after starting any kind of heparin.
- Thrombosis develops in about 50% of patients who have HIT.
- The most sensitive, readily available screening test for HIT is an enzyme-linked immunosorbent assay (ELISA) for anti-PF4 antibody.
- A pretest probability scoring system (the 4“T’s”) has been validated for the diagnosis of HIT, considering thrombocytopenia, timing of platelet fall, and thrombosis or other sequelae.
- The platelet count does not usually drop below 50,000/mcL in HIT; a lower platelet count suggests another etiology.
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Description
Test your knowledge of Thrombotic Thrombocytopenic Purpura (TTP) and Heparin-Induced Thrombocytopenia and Disseminated Intravascular Coagulation (DIC) with this comprehensive quiz. Review key points on diagnosis, treatment, and management of these critical hematologic disorders.