Sandbox:Asra

Asra Firdous,M.B.B.S.[1]

Management

INDICATIONS FOR TESTING Fatigue, weakness, pallor, dizziness, fainting

Check routine Labs, CBC , smear and reticulocyte count and index

Diagnosed as anemia if Hgb in males < 13g / dl and in females if Hgb < 12g / dl Check whether corrected reticulocyte index ≥ 2.5

If No Check RBC indices

If Yes then

Normal MCV / MCHC Normocytic Normochromic

Low MCV / MCHC Microcytic Hypochromic

High MCV Macrocytic

Check peripheral smear

↓ EPO production or improper response to EPO

Maturation defect

Maturation defect

Fragmented cells on peripheral smear

No fragmented cells on peripheral smear

*Bone marrow disorder Inflammation *Autoimmune disease *Chronic renal disease *Critical illness *Chronic endocrine disorders *Aplastic anemia *Pure red cell aplasia

*Iron deficiency *Chronic disease *Thalassemia (Hemoglobinopathies) *Sideroblastic anemia *Lead toxicity

*Folate, B12 deficiency (Megaloblastic Anemia) * Drug effect *Excessive alcohol use *Hypothyroidism

Suggests hemolytic process *Metabolic defect *Hemoglobinopathies (eg, sickle cell) *Autoimmune destruction *Splenic sequestration *RBC membrane defect *Intravascular hemolysis See Hemolytic Anemia

Suspect hemorrhage and acute blood loss

Abnormal peripheral smear

If yes then work up based on smear bone marrow biopsy may be necessary

If no

ORDER Iron and Iron Binding Capacity and Ferritin check B12, Folate levels

Start Vit B12,Folate If low

Low / normal TIBC Normal / high ferritin Low / normal iron

High TIBC Low iron Low ferritin

Inflammation / Chronic Disease Consider Biopsy in this case

Iron Deficiency anemia

Vomiting Diagnosis

Check ABCDE ❑ Airway ❑ Breathing ❑ Circulation ❑ Deformity ❑ Exposure

❑ Assess vital signs ❑ Obtain IV access ❑ NPO (if persistent vomiting)

Rule out life-threatening causes ❑ Pyloric stenosis ❑ Intestinal malrotation with volvulus ❑ Congenital intestinal obstruction ❑ Diabetic ketoacidosis ❑ Intussusception ❑ Necrotizing enterocolitis ❑ Gastroenteritis ❑ Meningitis ❑ Sepsis ❑ Shaken baby syndrome ❑ Hydrocephalus ❑ Congenital adrenal hyperplasia ❑ Inborn errors of metabolism ❑ Obstructive uropathy

Signs of dehydration

Yes

No

Fluid replacement therapy

Electrolyte imbalance

Yes

No

Treat electrolyte imbalance

Detailed history and physical examination

Regurgitation

True Vomiting

Reassurance and Follow-up in OPD

❑Frequency ❑ Effect on oral intake

Persistent and Hampering oralintake

Occasional and does not hamper oral intake

Antiemetics ❑ Ondansetron ❑ Domeperidone

Observation and Reassurance

Investigate and treat the underlying cause

Vomiting

❑Assess vital signs ❑Obtain venous access

Unstable

Stable

Stabilize hemodynamics

History and Physical Examination

Regurgitation

True Vomiting

Reassurance and follow-up in OPD

Red flag signs ❑ Unstable vital signs ❑ Acidotic breathing ❑ Bile and Blood present in vomiting ❑ Clinical features suggestive of GI obstruction ❑ Inconsolable cry and excessive irritability ❑ Altered sensorium

Yes

No

❑ ICU admission ❑ Stabilise ❑ Investigate for the underlying cause

Fever

Treat the underlying cause

Present

Absent

Infections

❑ Frequency of vomiting ❑ Effect on oral intake

Treat the underlying cause

Persistent/Recurrent vomiting Hampering oral intake

Occasional vomiting Not hampering oral intake

Antiemetics ❑ Ondansetron ❑ Domeperidone

Observation and Reassurance

Ewing's sarcoma Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Ewing's sarcoma from other diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Staging
History and Symptoms
Physical Examination
Laboratory Findings
Biopsy
X Ray
CT
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Sandbox:Asra On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Sandbox:Asra All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Sandbox:Asra
CDC on Sandbox:Asra
Sandbox:Asra in the news
Blogs on Sandbox:Asra
Directions to Hospitals Treating Ewing's sarcoma
Risk calculators and risk factors for Sandbox:Asra

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2];Associate Editor(s)-in-Chief: Suveenkrishna Pothuru, M.B,B.S. [3];Assistant Editor(s)-In-Chief: Michael Maddaleni, B.S., Asra Firdous, M.B.B.S.

Overview

Ewing's sarcoma is the second most common malignant bone neoplasm commonly affecting children and adolescents. It usually affects patients in the second decade of life with a peak incidence around 15 years of age. It comprises 3% of all malignancies in pediatric patients and about 10-15% of childhood bone cancers. The overall incidence of Ewing's sarcoma is approximately estimated at 2.9 cases per million population in the U.S. Ewing's sarcoma is more common in males than females. It is more prevalent in whites than Africans.

Epidemiology and Demographics

• Ewing's Sarcoma is the second most common bone malignancy in children and adolescents.
• 10-15% of childhood bone cancers are Ewing's Sarcoma.
• Ewing's Sarcoma constitutes about 4% of pediatric cancers.
• 200-250 new cases of Ewing's sarcoma are reported each year in the United States.
• Nearly, 60% of the Ewing Sarcoma cases have long-term disease-free survival.

Incidence

• The incidence of Ewing's sarcoma has remained unchanged for 30 years.
• In the United States, the overall incidence of Ewing's sarcoma is 1 cases per million individuals.
• During 1973-2004, the average annual incidence of Ewing's Sarcoma was estimated to be 2.9 cases per million population in the United States.
• The incidence of Ewing's Sarcoma, in the United States, is estimated to be 200-250 cases annually.

Mortality/Morbidity

The overall 5-year survival rate for patients with Ewing's Sarcoma is approximately 70% in primary lesions and 30% in metastatic disease.

Race

• Ewing's Sarcoma is more prevalent in Caucasians than Asians or Hispanics.
• African Americans and Africans are less likely to develop Ewing's Sarcoma.
• The incidence in the Caucasians is 1.5 cases per million population.
• The incidence in the Asians is 0.8 cases per million population.
• The incidence in Africans is 0.2 cases per million population.

Age

• Ewing's Sarcoma commonly affects children and adolescents between 10 and 20 years of age.
• The median age at diagnosis is 15 years
• In patients younger than 5 years, diagnosed in about 0.6 cases per million population.
• In patients aged 10-14 years, diagnosed in about more than 5 cases per million population.

Gender

• Males are more commonly affected than females. The male to female ratio is around 3:2.

Anemia of Prematurity Symptoms

The majority of patients with Anemia of Prematurity are asymptomatic. In premature infants with severe disease, symptoms are usually vague or non-specific.

• Common symptoms of Anemia of Prematurity include
  • Tachycardia
  • Tachypnea
  • Decreased activity or lethargy
  • Difficulty feeding
  • Pallor
• Less common symptoms of Anemia of Prematurity include
  • Poor weight gain despite adequate calorie intake
  • Breathing difficulties
  • Metabolic acidosis due to increased lactic acid production from anaerobic metabolism in the cells
  • Heart murmurs

Pathophysiology of Anemia of Prematurity

The pathogenesis of anemia of prematurity is multifactorial. Anemia of prematurity is the result of a combination of decreased erythropoietin production, increased erythropoietin metabolism, deficient iron stores, decreased RBC lifespan, and blood loss during phlebotomy.

Physiological anemia in newborns

Normally, all the newborns experience a fall in the haemoglobin concentration during the first few weeks of life. Healthy, fullterm infants usually develop anemia around 10-12 weeks of life after birth. Hemoglobin concentration never falls below 10 g/dl in healthy infants. Physiological anemia is well tolerated by and does not require any therapy.

• After birth, an embryo transitions from a hypoxic state in-utero to an infant in a relatively hyperoxic environment
• This transition leads to an increase in blood oxygen and tissue oxygen concentration in newborns
• Increased oxygen concentration inhibits erythropoietin production and eventually stops erythropoiesis
• Due to the rapid growth and disproportionate RBC production, hemoglobin levels fall gradually in infants
• The drop in hemoglobin concentration continues until the tissue hypoxia develops which usually takes around 6-12weeks after birth
• Tissue hypoxia activates the oxygen sensors present in the kidney and liver to stimulate the erythropoietin and red blood cells production
• Fullterm newborns have enough iron stores for erythropoiesis until 20 weeks of life
• Infants have a shorter RBC lifespan and increased erythropoietin metabolism when compared to adults

Pathological Anemia of Prematurity

In preterm infants, multiple physiological factors exaggerate and combine to result in pathological anemia. Hemoglobin levels drop rapidly to less than 10 g/dl around 4-6 weeks after birth. Infants with 1-1.5 kg of birthweight have hemoglobin levels around 8 g/dl, whereas infants with birthweight less than 1 kg have hemoglobin levels around 7 g/dl or less. The profound decrease in hemoglobin levels in premature infants produce abnormal signs and symptoms and require a blood transfusion.

• Iron transport from mother to infants and a greater proportion of fetal erythropoiesis occur during the third trimester. So, infants born prematurely have deficient iron stores required for the red blood cells production
• Blood loss during phlebotomy is the major contributor of anemia of prematurity
• Majority of preterm infants are sick and critically ill that require frequent blood sampling for various laboratory investigations needed for their clinical monitoring. The average amount of blood loss during sampling ranges from 0.8-3.1 ml/kg/day, a significant amount that requires replacement
• Preterm infants are at increased risk of nosocomial infections that lead to oxidative hemolysis
• In premature infants, liver is the major site of erythropoiesis. Liver EPO is less sensitive to anemia and tissue hypoxia
• Preterm infants have deficient Vitamin E, Vitamin B12, Folic acid stores required for red blood cells production
• A combination of blood loss, decreased erythropoietin production, deficient iron stores, increased erythropoietin metabolism, shortened RBC lifespan contribute to the development of anemia of prematurity

Vomiting

❑Assess vital signs ❑Obtain venous access

Unstable

Stable

Stabilize hemodynamics

History and Physical Examination

Regurgitation

True Vomiting

Reassurance and follow-up in OPD

Red flag signs ❑ Unstable vital signs ❑ Acidotic breathing ❑ Bile and Blood present in vomiting ❑ Clinical features suggestive of GI obstruction ❑ Inconsolable cry and excessive irritability ❑ Altered sensorium

Yes

No

❑ ICU admission ❑ Stabilise ❑ Investigate for the underlying cause

Fever

Treat the underlying cause

Present

Absent

Infections

❑ Frequency of vomiting ❑ Effect on oral intake

Treat the underlying cause

Persistent/Recurrent vomiting Hampering oral intake

Occasional vomiting Not hampering oral intake

Antiemetics ❑ Ondansetron ❑ Domeperidone

Observation and Reassurance