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  <head>
    <title>039-02 Marrow pattern recognition, clonal disease, and haematological emergencies</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Marrow patterns, clonal disease, emergencies">
      <outline text="Counts as dynamic marrow output">
        <outline text="Unit is count plus trend, film, lineages, tempo"/>
        <outline text="Niche regulates dormancy and lineage commitment"/>
        <outline text="Early stem-cell injury reduces all lineages">
          <outline text="Lineage-specific immune process: isolated cytopenia"/>
        </outline>
        <outline text="Clones fail to make useful cells in cellular marrow">
          <outline text="Pancytopenia does not mean empty marrow"/>
        </outline>
      </outline>
      <outline text="Leukocytosis and lymphocytosis">
        <outline text="Absolute differential and film come first"/>
        <outline text="Reactive: bands, toxic granulation, Döhle-like bodies"/>
        <outline text="Clonal: broad maturation, basophilia, blasts"/>
        <outline text="Glucocorticoids raise neutrophils rapidly">
          <outline text="Demargination and reduced tissue migration"/>
          <outline text="Lymphocytes and eosinophils often fall"/>
        </outline>
        <outline text="Monomorphic lymphocytes suggest a clone">
          <outline text="Flow cytometry shows light-chain restriction"/>
        </outline>
      </outline>
      <outline text="Neutropenic infection">
        <outline text="Inflammation becomes diagnostically silent">
          <outline text="Mucositis and devices breach barriers"/>
          <outline text="No pus, infiltrates, or local tenderness"/>
        </outline>
        <outline text="Fever may be the sole sign"/>
        <outline text="Cultures, then antipseudomonal regimen"/>
        <outline text="Low-risk discharge needs support and contact"/>
        <outline text="Persistent fever is not automatically resistance">
          <outline text="Abscess, mould, virus, drug, marrow recovery"/>
        </outline>
        <outline text="Avoid rectal procedures: mucosal injury"/>
        <outline text="Growth factor does not replace antibiotics"/>
      </outline>
      <outline text="Pancytopenia and marrow sampling">
        <outline text="Organised by cellularity and destruction">
          <outline text="Nutritional: macrocytosis, hypersegmentation"/>
          <outline text="Aplastic: hypocellular, no malignant replacement"/>
          <outline text="Infiltration: leukoerythroblastic film"/>
          <outline text="Hypersplenism sequesters several lineages"/>
        </outline>
        <outline text="Aspirate: morphology, flow, cytogenetics">
          <outline text="Dry tap with fibrosis or dense disease"/>
        </outline>
        <outline text="Trephine: architecture, fibrosis, focal infiltration"/>
        <outline text="Interpret mutations with morphology"/>
        <outline text="Inadequate sample negative is not absence"/>
      </outline>
      <outline text="Myelodysplastic and myeloproliferative neoplasms">
        <outline text="Clonal stem cells yield ineffective descendants">
          <outline text="Mutations predict progression to leukaemia"/>
          <outline text="Alcohol, copper, vitamins, drugs mimic dysplasia"/>
        </outline>
        <outline text="Allogeneic transplantation principal curative route"/>
        <outline text="Polycythaemia vera raises viscosity">
          <outline text="Leukocytes and platelets add thrombosis"/>
        </outline>
        <outline text="Thrombocythaemia bleeds via von Willebrand loss"/>
        <outline text="Myelofibrosis shifts production to spleen, liver"/>
      </outline>
      <outline text="Acute leukaemia and bleeding">
        <outline text="Differentiation failure with blast expansion">
          <outline text="May present with pancytopenia"/>
        </outline>
        <outline text="Flow sets lineage, genetics define entity"/>
        <outline text="Promyelocytes activate coagulation, fibrinolysis">
          <outline text="Differentiation therapy on suspicion"/>
        </outline>
        <outline text="Platelet count alone misstates bleeding risk">
          <outline text="Frequent coagulation tests, fibrinogen targets"/>
          <outline text="Avoid intramuscular injection and procedures"/>
        </outline>
      </outline>
      <outline text="Leukostasis">
        <outline text="Poorly deformable cells obstruct microvessels">
          <outline text="Lung and brain most affected"/>
        </outline>
        <outline text="Risk count differs by lineage"/>
        <outline text="Emergency cytoreduction and specialist care"/>
        <outline text="Transfusion further raises viscosity"/>
        <outline text="Leukapheresis cannot replace definitive therapy"/>
      </outline>
      <outline text="Lymphoma and plasma-cell disease">
        <outline text="Lymphoma diagnosis depends on architecture">
          <outline text="Excisional biopsy preferred when feasible"/>
          <outline text="Steroids shrink tissue and obscure diagnosis"/>
        </outline>
        <outline text="Biology outweighs stage for urgency"/>
        <outline text="Plasma-cell clones injure by mass and protein">
          <outline text="Osteoclast activation: lytic bone, hypercalcaemia"/>
          <outline text="Free light chains damage tubules"/>
        </outline>
        <outline text="Small clones cause amyloid or neuropathy"/>
      </outline>
      <outline text="Tumour lysis syndrome">
        <outline text="Release outpaces homeostasis">
          <outline text="Potassium causes arrhythmia"/>
          <outline text="Calcium phosphate deposits in kidney"/>
          <outline text="Uric acid obstructs tubules"/>
        </outline>
        <outline text="Prevention starts before cytotoxic treatment"/>
        <outline text="Allopurinol prevents, rasburicase degrades urate">
          <outline text="Post-rasburicase samples need cooling"/>
        </outline>
        <outline text="Casual calcium correction increases deposition"/>
      </outline>
      <outline text="Supportive care and transfusion">
        <outline text="Treatment trades control against reserve"/>
        <outline text="Residual disease is assay- and disease-specific"/>
        <outline text="Transfuse to symptoms and goals, not number"/>
        <outline text="Reaction: stop, recheck identity, assess"/>
        <outline text="Monitor alloimmunisation, iron, overload"/>
        <outline text="Irradiated or leukocyte-depleted by transplant plan"/>
        <outline text="Clear discharge thresholds and contacts"/>
      </outline>
    </outline>
  </body>
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