The only blood smears you need to know for the USMLE

Brief Tweetorial
5 Leukemias
5 Blood smears
Be able to differentiate them

1. AML
2. ALL
3. CML
4. CLL
5. Adult T-cell leukemia/lymphoma AML

Typically older patient, although can occur in younger patients.
Abrupt symptoms
Needs urgent Rx
Myeloblasts have Auer rods, but not always
However, if Auer rod seen it has to be AML
APL subtype t(15;17) commonly has Auer rods!

DOAC Jewels - Tweetorial

Effects of DOACs on Tests of Hemostasis

All⬆️PT (dabigatran slightly)
All ⬆️PTT (rivaroxaban/apixaban very slightly)

Mixing studies demonstrate incomplete correction

Dabigatran can falsely ⬆️fibrinogen
Only dabigatran ⬆️TT Anticoagulant Mechanism Name Jewels!

Drugs target Xa = Xa in name
ApiXaban
BetriXaban
EdoXaban
RivaroXaban

Drugs target BOTH Xa+thrombin = PARIN (pair) in name
HeParin
EnoXaParin
DalteParin

Drugs target only IIa = B (2nd letter)
ArgatroBan
Bivalrudin
DaBigatran

Below is a Tweetorial on all the things Vitamin D supplementation does not do based off high quality evidence (randomized controlled trials!)

Vitamin D does not prevent cancer
nejm.org/doi/full/10.10… Vitamin D does not prevent bone fractures
nejm.org/doi/full/10.10…

Tweetorial - How to learn an antibiotic!
Podcast up soon!

I learn following about every abx

Does it cover?
1. MSSA
2. MRSA
3. Enterococcus
4. Pseudomonas
5. Anaerobes
6. Scary gram negatives (ESBL)
7. Unique coverage (ampicillin = listeria)
8. Unique toxicity MRSA/Enterococcus

Ampicillin = Enterococcus

Ceftaroline = MRSA

Quinupristin/dalfopristin = VRE (faecium)

Vancomycin = MRSA+Enterococcus

MRSA+VRE
Daptomycin (Not lung infections)
Linezolid
Tigecycline
Telavancin

Community MRSA
Clindamycin
TMP-Sulfa (Bactrim)
Doxycycline

Diagnostic testing for monoclonal gammopathies!
A tweetorial for internists to clear some confusion!

Serum protein electrophoresis(SPEP)
Urine protein electrophoresis (UPEP)
Serum immunofixation (SIFE)
Urine immunofixation (UIFE)
Serum free light chains(sFLC) (kappa/lambda) Electrophoresis (SPEP/UPEP) = how much

Charge based separation of protein on gel
Low sensitivity
May miss small monoclonal proteins and light chains
Quantifies M-protein (g/dL)
Does not qualify M-protein (IgG, IgA, IgM, IgD, IgE)

USMLE Step 1/2 Review for Med Students!

Brief Tweetorial
5 Leukemias
5 Blood smears
Be able to differentiate them

1. AML
2. ALL
3. CML
4. CLL
5. Adult T-cell leukemia/lymphoma AML

Typically older patient, although can occur in younger patients.
Abrupt symptoms
Needs urgent Rx
Myeloblasts have Auer rods, but not always
However, if Auer rod seen it has to be AML
APL subtype t(15;17) commonly has Auer rods!

Recite this from your head. It's a good party trick.
(Tweetorial 1/10)

t(8;14) = MYC-IgH = BL
t(2;8) = IgK-MYC = BL
t(8;22) = MYC-IgL = BL
t(14;18) = IgH-BCL2 = FL
t(2;18) = IgK-BCL2 = FL
t(18;22) = BLC2-IgL = FL
t(11;14) = CCND1-IgH = MCL t(11;18) = API2-MALT1 = MZL H. pylori-
t(2;5) = NPM1-ALK = ALCL ALK+
t(6;7) = DUSP22-FRAH7H = ALCL ALK-
iso7q = HSTCL
inv(14) = t(14;14) = MTCP1 = T-PLL
t(X;14) = TCL1 = T-PLL
del(11q) = ATM = CLL (intermediate)
del(13q) = RB1 = CLL (good)
+12 = CLL (good)

The 4 most important blood smears for medical students for the USMLE and for life!

A short tweetorial/smearorial = 4 blood smears

Fevers, AMS, hemolytic anemia, thrombocytopenia =

TTP = ADAMTS13 deficiency
Rx plasmapheresis

Smear with schistocytes + thrombocytopenia 25 yo with bleeding, thrombocytopenia,⬇️fibrinogen = DIC

Smear with large promyelocytes with granules, blasts with Auer rods, schistocytes can be present from DIC

APL = t(15;17)
Rx ATRA

[ASH IMAGE BANK]

🩸🩸🩸A Papa Heme Tweetorial🩸🩸🩸

RCTs Restrictive vs Liberal pRBC Transfusion

Without going through the whole Tweetorial, the general gist is less = much more with blood transfusions.

Key Trials:
TRISS
TRICC
FOCUS
TRACS
Villanueva NEJM 2013 TRICC

Critically ill patients with Hb <9g/dL
Randomized to pRBC for <7 g/gL vs 10 g/dL

30 day mortality the same
⬇️ mortality in the less ill patients with restrictive strategy

Restrictive strategy possibly superior to a liberal transfusion strategy in critically ill patients

DOAC Jewels - Tweetorial

DOACs interfere with PT/PTT/TT!

⬆️PT
Xa inhib
RivaroXaban>EdoXaban>ApiXaban

⬆️PTT
DabigaTran>Xa inhib

⬆️TT
DabigaTran = Direct Thrombin Inhibitor

PT/PTT mix incomplete correction in presence of DOAC

Short review on subject ashpublications.org/hematology/art… Effects of DOACs on Tests of Hemostasis

All⬆️PT (dabigatran slightly)
All ⬆️PTT (rivaroxaban/apixaban very slightly)
Mixing studies demonstrate incomplete correction

Xa inhibitors (thos withe an X) ⬆️Anti Xa

Dabigatran can falsely ⬇️fibrinogen
Only dabigatran⬆️Thrombin Time

Cold Blood = A short Tweetorial!
To prevent move to San Diego

3 confusing diseases

1. Cold agglutinin disease
2. Cryoglobulinemia
3. Paroxysmal cold hemoglobinuria

2 of these disease are seen often on both the heme consult service and boards. Cold Agglutinin Disease

Hemolytic anemia precipitated by cold
Monoclonal IgM binds RBCs (I antigen), agglutination, and fixes complement in cold->hemolysis
DAT+ for C3 and - for IgG
Associated with IgM gammopathies/LPL
Polyclonal form after Mycoplasma infection
Rx = Rituximab

Pathology Images to Know for USMLE Step 1

Review this right before the test and get the questions right.

Pathologists add more if I am missing any key images

Granulomas - TB (caseating) vs. Sarcoid (non-caseating)

epomedicine.com/medical-studen… The Reed Sternberg Cell - Hodgkin Lymphoma - Owl Eyes

medicalopedia.org/3153/owls-eye-…

Tweetorial - How to learn an antibiotic!

I learn following about every abx

Does it cover

1. MSSA
2. MRSA
3. Enterococcus
4. Pseudomonas
5. Anaerobes
6. Scary gram negatives (ESBL)
7. Unique coverage (ampicillin = listeria)
8. Unique toxicity (imipenem = seizure) MRSA/Enterococcus

Ampicillin = Enterococcus

Ceftaroline = MRSA

Quinupristin/dalfopristin = VRE (faecium)

Vancomycin = MRSA+Enterococcus

MRSA+VRE
Daptomycin (Not lung infections)
Linezolid
Tigecycline
Telavancin

Community MRSA
Clindamycin
TMP-Sulfa (Bactrim)
Doxycycline

How to make Med Twitter a (mostly) enjoyable experience

A short tweetorial where I will share what I think. I have made many (if not all) the errors that can happen (which led to negative experiences)

But overall, Twitter has been good and has actually led to many new friends! 1.

When you first start out follow a bunch of people, even those who you may not share interests with (dare I say disagree with)!

Over time you will see who brings happiness to you and who doesn’t and you will unfollow. The algorithm will lead you to new accounts you may like

The 4 most important blood smears for medical students for the USMLE and for life

A short tweetorial = 4 blood smears

Fevers, AMS, hemolytic anemia, thrombocytopenia =

TTP = ADAMTS13 deficiency
Rx plasmapheresis

Smear with schistocytes + thrombocytopenia 25 yo with bleeding, thrombocytopenia,⬇️fibrinogen = DIC

Smear with large promyelocytes with granules, blasts with Auer rods, schistocytes can be present from DIC

APL = t(15;17)
Rx ATRA

[ASH IMAGE BANK]

1/9

My experience with United Healthcare insurance and Twitter as an oncologist trying to get a med approved for a patient with a rare cancer.

Unfortunately, similar stories play out at docs offices across the country.

There are no FDA approved meds for my patients diagnosis. 2/9

I placed an order for a med 7 days ago
No offer for a peer to peer. It was denied.

My pharmacy reached out to UH with no success. I was told to file an appeal.

I called the number and got an automated message with many options. I tried this a few times with no success.

Large Granular Lymphocytic Leukemias (LGL)
Tweetorial (1/7)

3 flavors:
1. T-cell LGL
2. Chronic lymphoproliferative disorder of NK cells
3. Aggressive NK cell leukemia

All have
LGL cells = Large lymphs+moderate/copious cytoplasm+prominent azurophilic granules+
reniform nucleus T-LGL

Indolent disorder of mature cytotoxic lymphocytes of effector memory cell phenotype

LGL count > 2 x 10^9 (can be less)

Clinical presentation:
Elderly
Isolated neutropenia
Anemia
Recurrent infections
Splenomegaly
No LAD
Rheumatoalogic conditions (see next Tweet)

Hypercalcemia: A Tweetorial for Internist

Calcium regulated to levels between 9-10.5 mg/dL

↑PTH = ↑calcium
↑Calcitonin = ↓calcium

PTH produced by the chief cells in parathyroid glands
Calcitonin produced by the parafollicular cells in thyroid PTH = ⬆️Ca ⬇️Phos

↑renal reabsorption Ca in distal tubule
↑urinary Phos excretion
↑release Ca from bones
Binds osteoblasts ↑ RANKL -> activates osteoclasts

↑25-OH D3 1-α hydroxylase -> vit D to active form (1,25-dihydroxy)
Active vit D ↑absorption of intestinal Ca

High Dose Methotrexate - Tweetorial

The Players!
MTX (>500 mg/m2)
Leucovorin (folinic acid)
Sodium bicarbonate
Glucarpidase (hopefully not!)

How we make thymidylate (dTMP)
FH2+NADH = FH4 via dihydrofolate reductase (DHFR)
dUMP+FH4 = dTMP via thymidylate synthase (TS) MOA of MTX
1. Enters cells via reduced folate carried
2. Polyglutamated (MTX-PG)
3. MTX-PG binds DHFR 1,000 fold greater than FA
4. Competitively inhibits conversion of FH2->FH4 via DHFR
5. No FH4 (dUMP+FH4 = dTMP)
6. No dTMP
7. Stops DNA synthesis
8. Cell dies

The 4 most important blood smears for doctors to know! (orthopods and eye docs I'll give a pass)

A short tweetorial/smearathon

HPI: Fevers, AMS, hemolytic anemia, thrombocytopenia

TTP = ADAMTS13 deficiency
Rx plasmapheresis

Smea r= schistocytes + thrombocytopenia HPI: 25 yo with bleeding, thrombocytopenia, ⬇️fibrinogen

Smear with large promyelocytes with granules, blasts with Auer rods, schistocytes can be present from DIC

APL = t(15;17)
Rx ATRA

[ASH IMAGE BANK]

Per pathologists, cancer cells (kind of) look like something else

Cleaved = Follicular lymph
Grapes = Mott cell = Myeloma
Horseshoe = Hallmark cell = ALCL
Brain = Cerebriform = Sezary
Kidney = Reniform = Langerhan's
Owl eyes = Reed Sternberg = cHL
Popcorn = NLPHL

Flower = ATLL Cleaved cell = Follicular lymphoma