Elevated lactate dehydrogenase (marker of tissue damage)
Reduction in haptoglobin (binds free hemoglobin [Hb])
UNnconjugated hyperbilirubinemia (byproduct of hemolysis)
*Be certain to check for increased reticulocytes ( bone marrow compensatory response) and blood smear (i.e Spherocytes, Schistocytes, Sickle cells)
W. Barcellini and B. Fattizzo, “Clinical Applications of Hemolytic Markers in the Differential Diagnosis and Management of Hemolytic Anemia,” Disease Markers, vol. 2015, Article ID 635670, 7 pages, 2015. doi:10.1155/2015/635670
Kato GJ, McGowan V, Machado RF, et al. Lactate dehydrogenase as a biomarker of hemolysis-associated nitric oxide resistance, priapism, leg ulceration, pulmonary hypertension, and death in patients with sickle cell disease. Blood. 2006;107(6):2279-2285. doi:10.1182/blood-2005-06-2373.
When you start a patient on Warfarin (i.e after a PE); there will be an overlap of administration of Warfarin and LMWH/ UFH for typically 5 days with a goal INR of 2-3. This is referred to as “Bridging“.
WHY? Warfarin introduces a temporary hypercoagulable stage during the first 36 hours. Protein C and Protein S (anti-coagulation factors) are vitamin K-dependent plasma proteins. Levels of these anti-coagulation factors drop faster than the pro-coagulation factors (10,9,7,2) we attempt to block with Warfarin. Therefore, bridging is used to counteract this transient pro-clotting state.
Esmon CT, Vigano-D’Angelo S, D’Angelo A, Comp PC. Anticoagulation proteins C and S. Adv Exp Med Biol. 1987;214:47-54.
Protein C / Protein S anticoagulant pathway. Anticoagulant pathway. Jeremy Parsons, M.D. (c) 2002-2016, PathologyOutlines.com, Inc.
Hypercalcemia affects up to a third of cancer patients and malignant hypercalcemia is the most common oncological emergency leading to hospitalization.
Most likely to occur in: breast cancer, multiple myeloma and lung cancer. However, it can also be found in other malignancies, including: gynecologic, renal and head & neck cancers
CAUSE: Increased osteoclastic bone resorption.
Solid tumours can produce parathyroid hormone–related protein (PTHrP), increasing calcium levels in the blood by activating parathyroid hormone receptors in tissue, which results in osteoclastic bone resorption; it also increases renal tubular resorption of calcium.
Bower M, Cox S. Endocrine and metabolic complications of advanced cancer. In: Doyle D, Hanks G, Cherny NI, Calman K, editors. Oxford textbook of palliative medicine. 3rd ed. New York, NY: Oxford University Press; 2004. pp. 688–90.
Lumachi F, Brunello A, Roma A, Basso U. Cancer-induced hypercalcemia. Anticancer Res. 2009;29(5):1551–5.
Seccareccia D. Cancer-related hypercalcemia. Canadian Family Physician. 2010;56(3):244-246.