Tumor lysis syndrome is a potentially life-threatening condition caused by the rapid breakdown of tumor cells during cancer treatment, releasing electrolytes into the bloodstream. It can cause severe electrolyte abnormalities like hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia. These abnormalities are due to the release of intracellular contents from dying tumor cells and can lead to acute kidney injury. Tumor lysis syndrome is most common in patients with high-grade lymphomas and leukemias undergoing aggressive chemotherapy and requires careful monitoring and prevention with hydration and medications to reduce complications.
Tumor lysis occurs when cancer cells release their contents into the blood stream, either spontaneously or following antineoplastic therapy leading to an influx of electrolytes and nucleic acids into the circulation.
The sudden development of hyperkalemia, hyperuricemia and hyperphosphatemia can have life-threatening end-organ effects on the myocardium, kidneys and CNS.
Hypocalcemia is a consequence of hyperphosphatemia in TLS.
Symptoms are variable from the metabolic derangements of TLS.
Tumor lysis occurs when cancer cells release their contents into the blood stream, either spontaneously or following antineoplastic therapy leading to an influx of electrolytes and nucleic acids into the circulation.
The sudden development of hyperkalemia, hyperuricemia and hyperphosphatemia can have life-threatening end-organ effects on the myocardium, kidneys and CNS.
Hypocalcemia is a consequence of hyperphosphatemia in TLS.
Symptoms are variable from the metabolic derangements of TLS.
Tumor Lysis Syndrome
The most common disease-related emergency encountered by physicians caring for children or adults with hematologic cancers
When tumor cells release their contents into the bloodstream, either spontaneously or in response to therapy-
leading to the characteristic findings of
hyperuricemia, hyperkalemia, hyperphosphatemia, and
hypocalcemia
Electrolyte and metabolic disturbances- progress to clinical toxic effects- including
-renal insufficiency,
-cardiac arrhythmias,
-seizures, and
-death due to multiorgan failure
Laboratory tumor lysis syndrome : Requires that two or more of the metabolic abnormalities occur within 3 days before or up to 7 days after the initiation of therapy
Clinical tumor lysis syndrome: Laboratory tumor lysis syndrome is accompanied by an increased creatinine level, seizures, cardiac dysrhythmia, or death.
IN MALIGNANCIES
–high proliferative rate,
–large tumor burden,
–high sensitivity to treatment-
Initiation of cytotoxic chemotherapy,
Cytolytic antibody therapy,
Radiation therapy,
Sometimes glucocorticoid therapy alone
Rapid lysis of tumor cells!!!!!
Releases massive quantities of intracellular contents:
K+ , phosphate, and nucleic acids
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tumor Lysis Syndrome
The most common disease-related emergency encountered by physicians caring for children or adults with hematologic cancers
When tumor cells release their contents into the bloodstream, either spontaneously or in response to therapy-
leading to the characteristic findings of
hyperuricemia, hyperkalemia, hyperphosphatemia, and
hypocalcemia
Electrolyte and metabolic disturbances- progress to clinical toxic effects- including
-renal insufficiency,
-cardiac arrhythmias,
-seizures, and
-death due to multiorgan failure
Laboratory tumor lysis syndrome : Requires that two or more of the metabolic abnormalities occur within 3 days before or up to 7 days after the initiation of therapy
Clinical tumor lysis syndrome: Laboratory tumor lysis syndrome is accompanied by an increased creatinine level, seizures, cardiac dysrhythmia, or death.
IN MALIGNANCIES
–high proliferative rate,
–large tumor burden,
–high sensitivity to treatment-
Initiation of cytotoxic chemotherapy,
Cytolytic antibody therapy,
Radiation therapy,
Sometimes glucocorticoid therapy alone
Rapid lysis of tumor cells!!!!!
Releases massive quantities of intracellular contents:
K+ , phosphate, and nucleic acids
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
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2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
Tumer lysis syndrom by Azazhu.pptx
1. SALALE UNIVERSITY COLLEGE OF HEALTH
SCIENCE DEPARTMENT OF ADULT HEALTH NURSE
MASTERS PROGRAM
Prepared by: Azazhu Abate, ID NO: 177/2015
Submitted to: Mr Tadele K. (BSC, MSc, Ass/t Prof)
Date: July 2023
Fitche, Ethiopia
2. Outline
• Introduction Tumor lysis syndrome
• Pathophysiology of Tumor lysis syndrome
• Clinical features of TLS
• Risk factors for TLS
• Diagnosis of TLS
• Prevention of TLS
• Treatment of TLS
• Prognosis of TLS
3. Objectives
At the end of seminar presentation, students will
be able to:
• Define the tumor lysis syndrome
• Discuss signs and symptoms of TLS
• Informed with risk factors of TLS
• Familiar with diagnosis, prevention and treatment
4. Tumor lysis syndrome
• Introduction: Tumor lysis syndrome is a group
of metabolic abnormalities that can occur as a
complication from the treatment of cancer,
where large amounts of tumor cells are killed
off from the treatment, releasing their contents
into the bloodstream.
5. Cont…
• TLS is oncologic emergency which is manifested
by severe electrolyte abnormalities such as
release of large amounts of-
Potassium
phosphate, and
nucleic acids into the systemic circulation as a
result of acute renal failure.
6. Cont…
• It is potentially life-threatening conditions that
happen within hours after cancer treatment
initiation of those fast-growing cancers,
especially cancers of the blood.
• It is most common in patients diagnosed with
leukemia .
7. Cont…
• It can also be seen in high-grade lymphomas
after the initiation of aggressive chemotherapy.
• Other solid tumors that can cause tumor lysis
syndrome are hepatoblastoma, neuroblastoma.
8. Pathophysiology
• Pathogenesis of TLS involves massive blood
tumor cell lysis resulting in the release of large
amounts of potassium, phosphate, and uric acid.
• Deposition of uric acid and calcium phosphate
crystals in the renal tubules may lead to acute
renal failure
9. Cont…
• This is often exacerbated by concomitant
intravascular volume depletion.
• The kidney normally excretes these products,
and consequently preexisting renal failure
exacerbates the metabolic derangements of
tumor lysis syndrome.
10. Clinical features
• Hyperkalemia: K is mainly an intracellular ion. High
turnover of tumor cells leads to spill of potassium into
the blood.
• Symptoms usually do not manifest until levels are
high (> 6.5 mmol/L) [normal 3.5–5.0 mmol/L] and
they include palpitations, cardiac conduction
abnormalities, and arrhythmias muscle weakness or
paralysis
11. Cont…
• Hyperphosphatemia: phosphates are also
predominantly intracellular.
• It causes acute kidney injury in tumor lysis
syndrome, because of deposition of calcium
phosphate crystals in the kidney parenchyma.
12. Cont…
• Hypocalcaemia: Because of the excess
phosphatemia, calcium is precipitated to form
calcium phosphate, leading to hypocalcaemia.
• Symptoms: tetany, paresthesias, muscle cramp
and weakness, sudden changes in mental
status, Parkinson like movement disorders,
papilledema
13. Cont…
• Hyperuricemia: massive cell death and
nuclear breakdown generates large
quantities of nucleic acids.
• Of these, the purines (adenine and
guanine) are converted to uric acid via the
purine degradation pathway and excreted
formation of urate crystals in the kidney.
14. Risk factors
• Risk factors for tumor lysis syndrome depend on
Different characteristics of the patient,
The type of cancer, and
The type of chemotherapy used.
15. Cont…
• Tumor characteristics: Tumors with a high cell
turnover rate, rapid growth rate and poorly
differentiated tumors tend to be more associated
with the development of tumor lysis syndrome.
• Example: Burkitt's lymphoma), Non-Hodgkin
Lymphomas (NHL), acute lymphoblastic
leukemia (ALL)
16. Cont…
• Patient characteristics: Certain patient-related
factors can affect the development of clinical
tumor lysis syndrome.
• These factors include elevated baseline
serum creatinine, kidney failure, dehydration,
and other issues affecting urinary flow or the
acidity of urine
17. Con…
• Chemotherapy characteristics: Chemo-sensitive
tumors, such as lymphomas, carry a higher risk for
the development of tumor lysis syndrome.
• Those tumors that are more responsive to a
chemotherapy agent carry a higher TLS risk.
• precipitating medication regimen includes
combination chemotherapy
18. Diagnosis
• TLS should be suspected in patients with large tumor
burden who develop acute kidney failure along with
hyperuricemia (> 15 mg/dL) or hyperphosphatemia
(> 8 mg/dL).
• The hyper secretion of uric acid can be detected with
a high urine uric acid - creatinine ratio > 1.0,
compared to a value of 0.6–0.7 for most other causes
of acute kidney failure.
19. Cont…
Diagnosis of TLS is based on two definitions
1. Cairo-Bishop definition: In 2004, Cairo and
Bishop defined a classification system for tumor
lysis syndrome
2. Howard definition: In 2011, Howard proposed a
refinement of the standard Cairo-Bishop definition
of TLS accounting for 2 limitations
20. Cairo-Bishop definition
1. Laboratory tumor lysis syndrome
abnormality in two or more of the following,
occurring within three days before or seven days
after chemotherapy.
uric acid > 8 mg/dL or 25% increase
potassium > 6 meq/L or 25% increase
phosphate > 4.5 mg/dL or 25% increase
calcium < 7 mg/dL or 25% decrease
21. Cont…
2. Clinical tumor lysis syndrome: laboratory
tumor lysis syndrome plus one or more of the
following:
– increased serum creatinine (1.5 times upper limit
of normal)
– cardiac arrhythmia or sudden death
– seizure
• A grading scale (0–5) is used depending on the
presence of lab TLS, serum creatinine,
arrhythmias, or seizures.
22. Howard definition
• Two or more electrolyte laboratory
abnormalities must be present simultaneously to
be considered related to TLS.
• In fact, some patients may present with one
abnormality, but later another one may develop
that is unrelated to the TLS (e.g., hypocalcaemia
associated with sepsis).
23. Cont…
• A 25% change from baseline should not be
considered a criterion since such increases are
rarely clinically important unless the value is
already outside the normal range.
• Moreover, any symptomatic hypocalcaemia
should constitute clinical TLS.
24. Prevention
• TLS prevention include aggressive hydration,
control of hyperuricemia with allopurinol and
rasburicase medications, and close monitoring of
electrolyte abnormalities.
• Allopurinol and rasburicase (which inhibits uric
acid production) works by preventing the
formation of uric acid following tumor cell lysis.
26. Prognosis
• The rate of mortality from tumor lysis syndrome
may vary widely depending on the type of
underlying malignancy. However, the occurrence
of acute kidney injury is concerning given the
high mortality that is generally associated with it.
27. Summary
• Tumor lysis syndrome is a potentially fatal metabolic
condition that occurs most frequently in patients with
rapidly proliferating, bulky, chemo sensitive tumors.
• TLS is oncologic emergency which is known by severe
electrolyte abnormalities such as release of large
amounts of Potassium, phosphate, and nucleic acids
into the systemic circulation as a result of acute renal
failure.
28. References
1. Davidson MB, Thakkar S, Hix JK, Bhandarkar ND, Wong A, Schreiber
MJ (April 2004). "Pathophysiology, clinical consequences, and
treatment of tumor lysis syndrome". The American Journal of
Medicine. 116 (8): 546–554.
2. Belay Y, Yirdaw K, Enawgaw B (2017). "Tumor Lysis Syndrome in
Patients with Hematological Malignancies". Journal of
Oncology. 2017: 9684909.
3. Darmon M, Malak S, Guichard I, Schlemmer B (September
2008). "Acute tumor lysis syndrome: a comprehensive
review". Revista Brasileira De Terapia Intensiva. 20 (3): 278–285.