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The current COVID-19 pandemic requires revisiting our current approach to major blood disorders, including ITP (Immune Thrombocytopenia), stirring up the production of several disease-specific practical guidelines. This report describes an updated version of consensus-based practical guidelines on the management of ITP, adapted to the Italian health system and social context. It highlights the role of the hematologist in offering guidance for choosing differentiated approaches in relation to specific circumstances and is intended to provide them with a useful tool for sharing the decision-making process with their patients. Probably, the greatest risk to avoid for a patient with suspected, ongoing or relapsed ITP - that is not severe enough to place him or her at risk for major bleeding - is to be infected in non-hospital and hospital healthcare settings. This risk must be carefully considered when adapting the diagnostic and therapeutic approach. More in detail, the document first addresses the appropriate management for COVID-19 negative patients with newly diagnosed ITP or who experience a relapse of previous ITP, according to first and second lines of treatment and then the management of COVID-19 positive patients according to their severity, from paucisymptomatic to those requiring admission to Intensive Cure Units (ICU). The pros and cons of the different treatments required to correct platelet count are discussed, as are some specific situations, including chronic ITP, splenectomy, thromboembolic complication and anti COVID-19 vaccination. [ABSTRACT FROM AUTHOR]

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the subsequent pandemic have impacted every aspect of oncology care worldwide. Healthcare systems have been forced to rapidly change practices in order to maximize the safety of patients and healthcare providers and preserve scare resources. Patients with acute myeloid leukemia are at increased risk of complications from SARS-CoV-2 not only due to immune compromise related to the malignancy but also due to the acuity of the disease and intensity of treatment. These issues have created unique challenges during this difficult time. In this article, we present the approaches taken by two groups of hematologist/oncologists, one in the United States and one in Italy, who have been caring for acute myeloid leukemia (AML) patients in the face of the pandemic. [ABSTRACT FROM AUTHOR]

Hemophilia therapeutics are evolving rapidly. Comprehensive care must also evolve to embrace this change. Online tools and guidelines are widely available to optimize prophylaxis with conventional clotting factor concentrates using an individual's predicted pharmacokinetic profile. Novel hemostatic agents (e.g. biphenotypic antibody) are also becoming widely available, with other agents with differing mechanisms of action in final stages of trial. Contemporary issues including challenges of prophylaxis; bleed treatment; laboratory monitoring and inhibitor risk/surveillance are summarized in this narrative review, focusing on how a re-personalization of education and treatment will be necessary to meet these challenges of the rapidly changing therapeutic landscape. [ABSTRACT FROM AUTHOR]

Background: Congenital factor V deficiency, also called parahemophilia, is a rare hematological disorder that can be treated with platelet transfusion.Case Presentation: A 27-year-old G2P0100 with factor V deficiency was admitted for induction of labor and requested labor epidural analgesia. Throughout her hospital course, factor V levels were managed per recommendation from her hematologist, which included transfusing fresh frozen plasma (FFP) to maintain a factor V level of 50% before any neuraxial technique and 40% for postpartum hemostasis. The parturient required multiple transfusions of FFP to stay at this level, which eventually resulted in pulmonary edema. Given the request to maintain high levels of factor V, the parturient was transfused with platelets as an alternative source of factor V. The parturient eventually delivered a healthy neonate without signs of postpartum hemorrhage or epidural hematoma.Conclusion: A major learning point from this case is that platelet transfusion is an effective alternative in the management of factor V deficiency. Factor V released by platelets has enhanced procoagulant function, resulting in local factor V concentrations 100 times more than that of plasma, and has a significantly extended half-life. Platelet transfusion should be considered as a therapy in treating parturients with factor V deficiency. [ABSTRACT FROM AUTHOR]

Gene therapy has the potential to revolutionise treatment for patients with haemophilia and is close to entering clinical practice. While factor concentrates have improved outcomes, individuals still face a lifetime of injections, pain, progressive joint damage, the potential for inhibitor development and impaired quality of life. Recently published studies in adeno‐associated viral (AAV) vector‐mediated gene therapy have demonstrated improvement in endogenous factor levels over sustained periods, significant reduction in annualised bleed rates, lower exogenous factor usage and thus far a positive safety profile. In making the shared decision to proceed with gene therapy for haemophilia, physicians should make it clear that research is ongoing and that there are remaining evidence gaps, such as long‐term safety profiles and duration of treatment effect. The eligibility criteria for gene therapy trials mean that key patient groups may be excluded, eg children/adolescents, those with liver or kidney dysfunction and those with a prior history of factor inhibitors or pre‐existing neutralising AAV antibodies. Gene therapy offers a life‐changing opportunity for patients to reduce their bleeding risk while also reducing or abrogating the need for exogenous factor administration. Given the expanding evidence base, both physicians and patients will need sources of clear and reliable information to be able to discuss and judge the risks and benefits of treatment. [ABSTRACT FROM AUTHOR]

Introduction: Patient–physician shared decision‐making (SDM) has become increasingly seen as having a positive effect on management of chronic diseases. However, little is known of the factors that encourage SDM or how effective it may be at improving health outcomes or how cost‐effective it is. Aim: To investigate the uses and applications of patient physician–SDM in the management of haemophilia and the influence of healthcare systems in the United States and the United Kingdom. Methods: This was a qualitative study based on interviews with treatment experts in the United States and United Kingdom. A grounded theory approach was used to analyse the data from the transcribed interviews and themes that emerged as related to the decision influencers. Twelve physicians from each country were interviewed by the author. Results: Treatment guidelines were viewed as having only limited applicability because of the lack of universal best options in haemophilia. The US physicians in the sample appeared to be more influenced by patient preferences than physicians in the UK, who instead tended to follow policies and standards of care more closely. Physicians in both countries commented that many of their patents had become highly knowledgeable of their bleeding disorder. US physicians were sometimes limited by insurance company policies but also reported that they were often successful in appealing insurance decisions. Conclusion: The research suggests that there are different influences on decision‐making between healthcare systems; patients and overarching healthcare systems play a major role in how physicians treat haemophilia. [ABSTRACT FROM AUTHOR]

Aim: The purpose of this research was to provide haemophilia treatment centres (HTCs) with guidance for the potential development of appropriate and timely interventions related to employment and vocational counselling and supports. Methods: A multi‐method approach was employed, where initial focus groups (n = 13) and review of the literature were used to construct a structured survey instrument (n = 75). Results: Focus group participants made choices about employment with keen awareness of how their bleeding disorder might limit them physically; they described the role of social networks in career choices; and they wrestled with issues of disclosure. Among survey respondents, 47% per cent of respondents reported that haemophilia had a small negative impact, 27% felt that it had a moderate negative impact and 13% indicated that it had a very large negative impact. One‐third of respondents had at some point received employment‐related advice from a member of their haemophilia treatment centre team. Roughly two‐thirds of respondents suggested that vocational advice would be "somewhat" or "very" useful at present. Conclusion: Canadian men with haemophilia continue to experience challenges related to employment and career development. There appears to be an opportunity for HTCs to incorporate additional supports on these topics into the range of services which they currently provide. [ABSTRACT FROM AUTHOR]

Solitary plasmacytoma is an infrequent form of plasma cell dyscrasia that presents as a single mass of monoclonal plasma cells, located either extramedullary or intraosseous. In some patients, a bone marrow aspiration can detect a low monoclonal plasma cell infiltration which indicates a high risk of early progression to an overt myeloma disease. Before treatment initiation, whole body positron emission tomography-computed tomography or magnetic resonance imaging should be performed to exclude the presence of additional malignant lesions. For decades, treatment has been based on high-dose radiation, but studies exploring the potential benefit of systemic therapies for high-risk patients are urgently needed. In this review, a panel of expert European hematologists updates the recommendations on the diagnosis and management of patients with solitary plasmacytoma. [ABSTRACT FROM AUTHOR]

Purpose Novel therapy has dramatically changed the outcome of patients with myeloma. Current National Comprehensive Cancer Network guidelines give bortezomib-based combinations a central role in the management of multiple myeloma (MM). The aim of this survey is to assess the use of bortezomib for the treatment of MM by hematologists practicing in Nigeria. Materials and Methods This is a cross-sectional observational survey. A structured, prevalidated questionnaire was self-administered to different cadres of hematologists. Data collected were analyzed using SPSS software version 21 (IBM, Chicago, IL). Results There were 54 respondents from 24 centers across the country. The most frequently used drugs for first-line therapy were thalidomide (66.7%), dexamethasone (54.2%), and bortezomib (48%), and a combination of bortezomib, thalidomide, and dexamethasone (16.7%) was the most frequently used first-line regimen. Of the 54 hematologists, 39 (72.2%) had prescribed bortezomib previously; no one had used bortezomib as monotherapy. Drug unavailability (86.7%) and cost (46.7%) were the major reasons for those who had not prescribed bortezomib. Approximately 56.4% of responders had patients who had experienced adverse effects, of which neuropathy was the most common (86.3%). Conclusion Bortezomib, thalidomide, and dexamethasone was the most frequently used first-line regimen to treat myelomatosis. Thalidomide and dexamethasone were the most frequently used drugs in myeloma treatment. Despite poor access to health care, coupled with the high cost and poor availability of bortezomib in our low- or middle-income country, those who prescribed bortezomib did so frequently (in more than half of their patients). [ABSTRACT FROM AUTHOR]

Background Ruxolitinib is established as treatment for symptomatic myeloproliferative neoplasm (MPN)-associated myelofibrosis. The strict inclusion and exclusion criteria and dose modification rules that applied to the COMFORTI and II studies that led to the licensing of ruxolitinib are not always applicable to routine clinical practice. Thus physicians now face decisions regarding ruxolitinib use that were not addressed in these pivotal trials. Methods We performed an online survey of hematologists practicing in Europe, Israel, the United Kingdom and the United States. Demographic details regarding the physicians and their practice as relates to MPNs were collected. Management decisions pertaining to the use of ruxolitinib were obtained regarding 10 clinical scenarios relating to anemia, thrombocytopenia, frailty, infection and lack or loss of response to ruxolitnib in MF patients. Results 140 physicians responded to the survey. There were marked differences regarding their decisions for ruxolitinib administration in MF patients with or developing anemia or thrombocytopenia. Similarly there was little consensus regarding management of patients refractory or losing a response to ruxolitinib. There were differences between “MPN-focused” and “non-MPN-focused” physicians in certain areas. Conclusion Physician practices regarding management of MF patients experiencing ruxolitinib-related toxicities or in whom response to the drug is lost was variable. This was true of “MPN-focused” and “non-MPN-focused” physicians in certain cases. Physician education and experience in using ruxolitinib may improve patient management. [ABSTRACT FROM AUTHOR]

Microangiopathic hemolytic anemia (MAHA) requires an aggressive approach since primary thrombotic microangiopathy syndromes such as thrombotic thrombocytopenic purpura (TTP) can progress rapidly to a fatal outcome. Differential diagnosis can be challenging even for an experienced hematologist. We present a case of a 52-year-old male who presented with symptoms of mesenteric panniculitis and showed signs of MAHA. His condition was attributed to severe vitamin B12 deficiency secondary to chronic atrophic gastritis and initiation of appropriate therapy was met with complete resolution of symptoms and normalization of hematologic parameters. [ABSTRACT FROM AUTHOR]

Purpose: To describe patient- and practice-related factors that physicians report affect their clinical decision to administer prophylactic pegfilgrastim to patients <24 h after completion of a myelosuppressive chemotherapy cycle (i.e., "same-day" pegfilgrastim).Methods: Oncologists, hematologists, and hematologist-oncologists enrolled in a US national physician panel were invited to participate in a cross-sectional, web-based survey to assess physicians' reasons for prescribing "same-day" pegfilgrastim. Physicians were screened as eligible if they reported prescribing "same-day" pegfilgrastim within the previous 6 months. The survey assessed physician perspectives and physician-perceived patient/caregiver preferences.Results: Of 17,478 invited physicians, 386 answered the screening questions; 151 (39.1 %) were eligible, agreed to participate, and completed the survey. Physicians estimated that overall 41.3 % of their patients treated with myelosuppressive chemotherapy received pegfilgrastim and that 31.6 % treated with pegfilgrastim received it on a "same-day" schedule. Approximately 36 % of physicians relied primarily on their clinical judgment when deciding to administer "same-day" pegfilgrastim. The clinical consideration reported most commonly by physicians as moderately or very important when deciding to administer "same-day" pegfilgrastim was previous febrile neutropenia (77.6 %). The most important patient-related consideration in the decision to administer "same-day" pegfilgrastim was patient/caregiver travel distance, and the most important practice-related consideration was the burden to the physician's practice of "next-day" administration (vs. same-day), reported by 84.7 % and 65.1 % of physicians as moderately or very important, respectively.Conclusions: While clinical judgment, patients' risk factors, and practice burden were principal influences favoring "same-day" pegfilgrastim administration, physician-perceived patient preferences and logistical barriers also have important roles in this decision. [ABSTRACT FROM AUTHOR]

Purpose: Treatment recommendations for patients with polycythemia vera (PV) are well established. Most multicenter trials investigating novel therapeutic strategies for PV are developed and conducted at university hospitals and specialized academic centers. The majority of patients in Germany, however, are treated in an outpatient (ambulatory) setting. The aim of this study was to evaluate the 'real-life' situation in a cohort of 1467 patients by analyzing data from a survey conducted at private practices and primary care centers. Methods: Eligible private practices and primary care centers treating patients with MPN were recruited to participate in a paper-pencil-based survey conducted from March 2015 until March 2016 in Germany. Hematologists were asked to report from patient charts. Descriptive analyses were conducted to assess for outcomes examined by reported prognostic risk scores, symptom scores and clinical response criteria. Results: In total, 34 centers participated in our retrospective survey and provided data on 1476 patients. Most patients were of older age (66.7 % older than 66 years of age), which was the main risk factor according to the criteria published by Tefferi and colleagues. Molecular status at diagnosis was not evaluated in 23 % of patients. Low rates of constitutional symptoms were reported in this physician-based survey with concentration problems, fatigue and itching being the main PV-related symptoms. Phlebotomy and hydroxyurea were the main cytoreductive measures for hematocrit control. The majority of patients were responsive (67.8 %) and tolerant (77.3 %) to hydroxyurea therapy. Interferon and JAK inhibitor therapy were used in <10 % of patients, respectively. Overall, leukocytosis, thrombocytosis and hematocrit could be effectively controlled by any therapy applied. Lack of efficacy was reported on reduction of constitutional symptoms and splenomegaly. Conclusions: The patient population investigated was older than participants in published large multicenter trials. The majority of patients were categorized as 'high risk.' Age was the main risk factor. Molecular status was unavailable in the majority of patients diagnosed prior to 2008. The physician-based survey reported on significantly lower rates of constitutional symptoms than patient-based surveys in the literature. Consistent with previously published reports, hydroxyurea is the main agent used for PV therapy in an outpatient setting resulting in efficient control of hematopoietic parameters. Constitutional symptoms and splenomegaly, however, may not be reduced efficiently, which could be improved by the use of JAK inhibitor treatment for high-risk patients in the future. [ABSTRACT FROM AUTHOR]

In the setting of an inherited or acquired thrombophilia, managing a gynecologic concern can be challenging. Nonetheless, careful consideration of the history along with a team approach to management, in which hematologists and gynecologists work together is critical. Thombophilias are important to understand, because certain types pose more risk than others. In addition, it is important to balance baseline factors, which might affect decisions regarding the best way to manage a concurrent gynecologic condition. Relative risks for thrombosis have been well studied for a variety of inherited and acquired conditions. Because of these risks, organizations such as the Centers for Disease Control and Prevention, World Health Organization, and American College of Obstetricians and Gynecologists have compiled clinical guidance recommendations to aid providers when hormonal management might be necessary (ie, to treat conditions such as delayed puberty, ovarian cysts, heavy menstrual bleeding, contraception). It is important to use these resources because there are limited prospective studies on this specific population who present with concurrent gynecologic conditions. [ABSTRACT FROM AUTHOR]

Elderly patients with diffuse large B-cell lymphoma (DLBCL) are frequently not treated with standard immunochemotherapy, and this influences survival negatively. The purpose of this study was to gain more insight into treatment decision-making by hematologists. Case vignettes concerning patients with DLBCL were presented to hematologists in the Netherlands. Patient characteristics (age, comorbidity) differed per case. Respondents were asked in each case if they would treat the patient with curative intent by means of full-dose chemotherapy or chemotherapy with dose reduction or if they would not treat the patient with curative intent. The vast majority of respondents would treat an elderly patient diagnosed with DLBCL without a relevant medical history with full-dose chemotherapy irrespective of age. In the presence of comorbidity, lack of social support, cognitive disorders, and untreated depression dose reductions in advance are frequently applied or patients are not treated with curative intent. This is most pronounced for patients aged older than 80 years. Respondents working in a university hospital more frequently refrain form full-dose chemotherapy with curative intent compared to respondents working in tertiary medical teaching hospitals or general hospitals. Patients without a relevant medical history are generally treated with curative intent irrespective of age. Cognitive disorders, comorbidity, and depression reduce the change of being treated with curative intent. This is most prominent in the eldest patient category. [ABSTRACT FROM AUTHOR]

We present a comprehensive study of a new infectious disease in immune compromised patients, neoehrlichiosis. The clinical picture of the disease can be misleading because the symptoms may be misinterpreted to be a worsening of the underlying disease.Background. Candidatus Neoehrlichia mikurensis is a newly discovered noncultivatable bacterium spread among ticks and rodents in Europe and Asia that can infect humans, particularly immunocompromised patients.Methods. We compiled clinical and laboratory data from 11 patients with hematological malignances or autoimmune diseases who were diagnosed with Candidatus N. mikurensis infection in Europe 2010–2013. Both published (6) and unpublished cases (5) were included.Results. The patients had a median age of 67, were mostly male (8/11), and resided in Sweden, Switzerland, Germany, and the Czech Republic. All but one had ongoing or recent immune suppressive treatment and a majority were splenectomized (8/11). Less than half of them recalled tick exposure. The most frequent symptoms were fever (11/11), localized pain afflicting muscles and/or joints (8/11), vascular and thromboembolic events (6/11), that is, deep vein thrombosis (4), transitory ischemic attacks (2), pulmonary embolism (1), and arterial aneurysm (1). Typical laboratory findings were elevated C-reactive protein, leukocytosis with neutrophilia, and anemia. Median time from onset of symptoms to correct diagnosis was 2 months. In at least 4 cases, the condition was interpreted to be due to the underlying disease, and immunosuppressive therapy was scheduled. All patients recovered completely when doxycycline was administered.Conclusions. Candidatus N. mikurensis is an emerging tick-borne pathogen that may give rise to a systemic inflammatory syndrome in persons with hematologic or autoimmune diseases that could be mistaken for recurrence of the underlying disease and/or unrelated arteriosclerotic vascular events. Awareness of this new pathogen is warranted among rheumatologists, hematologists, oncologists, and infectious disease specialists. [ABSTRACT FROM AUTHOR]

Abstract: Vascular anomalies include vascular tumors and vascular malformations. With growing pharmacologic options and parallels to cancer treatment and biology, the hematologist–oncologist has assumed a more prominent role in clinical care and research relating to these diagnoses. This also is a growing area for targeted therapies and drug repositioning. We performed a review of contemporary options for medical management of these lesions. PubMed was searched for “vascular anomaly”, “hemangioma”, “vascular malformation”, “arteriovenous malformation”, “capillary malformation”, “cerebral cavernous malformation”, “lymphatic malformation”, and “venous malformation”, each with “drug treatment” as a modifier. Manuscripts were reviewed to verify diagnoses, indications for treatment, dose-schedules, evidence of effectiveness, toxicities, and mechanisms of action. ClinicalTrials.gov also was reviewed for relevant trials. More than 20 agents were identified which have been used to treat vascular anomalies. Rigorous studies are lacking for many of these. The rarity of these tumors has limited development of medical approaches to treatment. Cooperative group trials will be needed to prove the effectiveness of drugs which have shown promise in cases and small series. The observant clinician remains a powerful tool for identifying potential new treatments for vascular tumors and malformations. [Copyright &y& Elsevier]

Antibiotic Control Programs were recommended by World Health Organization in order to minimize microbial resistance, provide the best therapy for patients, at the lowest costs for the healthcare institutions. We assessed the functionality of the Antibiotic Control Program in the Emergency County Hospital Brasov, over a period of two years (2004 - 2005). Method. This is a prospective descriptive study, based on the consults' data, computed as daily entries into an excel table, by the infectious diseases specialist. Results. 670 infectious diseases consults were performed. 89% of the requests for therapy were for prescription of common antibiotics; approval of a restricted antibiotic represented 64% of the requests (p=0,0001). The direct communication between the physicians and the infectious diseases specialist was very good in 60% of the cases. This was significantly better with hematologists (82%) and internists (68%) than with intensivists (51%) or surgeons (51%); p<0,05. The adherence to the recommendations of the infectious diseases specialist was of 88%, 93% in the internal medicine department and 83% in the intensive care unit (p<0,05). The incidence of nosocomial infections was 26%. In 93 of the 124 patients (75%) with nosocomial infections, therapy with a restricted antibiotic was prescribed, but 17 of the patients died (14%). All of these patients benefited from therapy with at least one of the new antibiotics. Conclusions. The Antibiotherapy Control Program proved to be functioning successfully, in spite of the implementation difficulties in ICU and surgery. The program did in no way obstruct administration of ACP restricted antibiotics to patients with nosocomial infections. [ABSTRACT FROM AUTHOR]

Bisphosphonates are effective in the prevention and treatment of bone disease in multiple myeloma (MM). Osteonecrosis of the jaw is increasingly recognized as a serious complication of long-term bisphosphonate therapy. issues such as the choice of bisphosphonate and duration of therapy have become the subject of intense debate given patient safety concerns. We reviewed available data concerning the use of bisphosphonates in MM. Guidelines for the use of bisphosphonates in MM were developed by a multidisciplinary panel consisting of hematologists, dental specialists, and nurses specializing in the treatment of MM. We conclude that intravenous pamidronate and intravenous zoledronic acid are equally effective and superior to placebo in reducing skeletal complications. Pamidronate is favored over zoledronic acid until more data are available on the risk of complications (osteonecrosis of the Jaw). We recommend discontinuing bisphosphonates after 2 years of therapy for patients who achieve complete response and/or plateau phase. For patients whose disease is active, who have not achieved a response, or who have threatening bone disease beyond 2 years, therapy can be decreased to every 3 months. These guidelines were developed in the interest of patient safety and will be reexamined as new data emerge regarding risks and benefits. [ABSTRACT FROM AUTHOR]

Hematologists have classically been the treating physicians of patients with Gaucher disease, and today, despite both specific and symptomatic therapeutic advances, they remain at the forefront of specialists to whom patients with Gaucher disease present. It is therefore appropriate to review that has changed and what has remained the same in hematological signs and symptoms of the disease in the decade and a half since therapy has become available. [ABSTRACT FROM AUTHOR]

Background: Control of oral anticoagulant treatment has been reported to be suboptimal, but previous studies suggest that patient self-management improves control. Objective: To compare the quality of control and the clinical outcomes of oral anticoagulant treatment in self-managed patients versus patients following conventional management. Design: Randomized, controlled trial. Setting: University-affiliated hospital in Spain. Patients: 737 patients with indications for anticoagulant treatment. Intervention: The self-management group (n = 368) received simple instructions for using a portable coagulometer weekly and self-adjusting treatment dose. The conventional management group (n = 369) received usual care in an anticoagulation clinic (monthly measurement and control of international normalized ratio [INR], managed by hematologists). Measurements: Percentage of INR values within the target range and major related complications. Results: The median follow-up period was 11.8 months (range, 0.3 to 16.9 months). The unadjusted percentages of in-range INRs were 58.6% in the self-management group and 55.6% in the conventional management group (difference, 3.0 percentage points [95% CI, 0.4 to 5.4 percentage points]). Twenty-seven patients (7.3%) in the conventional management group and 8 (2.2%) in the self-management group had major complications related to anticoagulant treatment. The unadjusted risk difference for major complications between groups was 5.1 percentage points (exact 95% CI, 1.7 to 8.5 percentage points). Fewer patients had minor hemorrhages in the self-management group (14.9%) than in the conventional management group (36.4%). Fifteen patients (4.1 %) in the conventional management group and 6 (1.6%) in the self-management group died (unadjusted risk difference, 2.5 percentage points [exact 95% CI, 0.0 to 5.1 percentage points]). Limitations: The trial was performed at only I center and was not blinded. The dropout rate in the intervention group was 21%. Conclusions: Compared with conventional management by an anticoagulation clinic, self-management of oral anticoagulant treatment achieved a similar level of control. Of note, major complications and minor hemorrhages were less common in the self-management group. [ABSTRACT FROM AUTHOR]

Abstract Patients with haematological malignancies are not referred to palliative care services as frequently as those with solid cancers (non haematological malignancies). The present study surveyed haematologists in Australia and New Zealand. We aimed to record theoret­ical referral times, identify problems with referral to palliative care and clarify elements used to decide whether a patient was ‘terminally ill’. A questionnaire based on the case-histories of three patients (with acute leukaemia, lymphoma or mul­tiple myeloma) was distributed at the Haematology Society of Australia and New Zealand Congress 2000, Perth, Australia. Each case was divided into stages by transitional points in the illness to include issues or prognostic variables that may stimulate referral to ­palliative care. Questions were asked about: (i) referral ­triggers, (ii) problems previously experienced, (iii) definition of when the patient was ‘terminally ill’, (iv) prognostication difficulties and (v) communication about prognosis. The response rate was 11%, which may represent up to 32% of Australian specialists. Eighty per cent had access to all types of palliative care services and refer for symptom control, regardless of illness stage. Twenty-nine per cent had experienced difficulties in referring. There was a variation as to exactly when referral would occur and when each case was considered ‘terminally ill’. Reasons for early or later referral were explored. Prognostication difficulties were common. In theory there is a willingness to refer to palliative care, however this has yet to be translated to day-to-day practice. This may be due to prognostication difficulties, logistical factors and medical concerns. Models of referral are suggested for further study. (Intern Med J 2003; 33: 566−571) [ABSTRACT FROM AUTHOR]

The author presents the special supplement "Transfusion, Thrombosis and Management of Bleeding" as a collaboration among anaesthetists, haematologists and surgeons for a comprehensive guide to all things related to blood. Topics discussed include efforts to reduce transfusion through faster testing-based protocols, the increased use of haemostatic blood components like fresh frozen plasma, platelets and cryoprecipitate and the increasing use of point-of-care testing.

: PurposeTo report a rare complication, delayed suprachoroidal hemorrhage, of needle revision of a nonfunctioning trabeculectomy bleb in a patient with previously undetected hairy cell leukemia.: DesignInterventional case report.: MethodsAn 89-year-old man presented with massive delayed suprachoroidal hemorrhage after needle revision of a trabeculectomy bleb.: ResultsRoutine investigations before choriodal drainage showed a low platelet count. Anterior chamber washout and choroidal drainage were done after intravenous platelet infusions. Subsequently, the diagnosis of hairy cell leukemia was made by the hematologist.: ConclusionsDelayed suprachoroidal hemorrhage is a rare but devastating complication of needle revision of trabeculectomy blebs and should be borne in mind while performing this seemingly trivial outpatient procedure. [Copyright &y& Elsevier]

A case study is presented which examines a 42-year-old male patient's treatment following an acute promyelocytic leukemia (APL) diagnosis, and it mentions an abnormal white blood cell count and the patient's symptoms which include spontaneous ecchymoses (bruises) and epistaxis (nosebleed). The administration of all-trans retinoic acid (ATRA) to the patient is addressed, along with a consultation with a hematologist and a bone marrow biopsy.