A comparison of global coagulation assays between normal controls and patients with thrombocytopenia.

INTRODUCTION: Some patients with thrombocytopenia may be at risk of bleeding although quantitative platelet count is not always a sufficient predictive factor. Global coagulation assays such as thromboelastography (TEG® ), calibrated automated thrombogram (CAT) and overall haemostatic potential (OHP) may provide a better assessment of an individual's haemostatic profile. METHODS: Blood samples were collected from thrombocytopenic patients. TEG® was performed on citrated whole blood, while CAT and OHP were performed on platelet-poor plasma. Results were compared to our previously collected normal controls. RESULTS: Fifty-eight participants (24 immune thrombocytopenia, 34 chemotherapy/malignancy-related) with mean age of 57.5 years were recruited. Compared to normal controls, thrombocytopenic participants had comparable maximum amplitude but reduced clot lysis (0.0% vs 0.6%; P < 0.001) on TEG® with reduced endogenous thrombin potential on CAT (1252.2 vs 1353.0 nmol/L/min; P = 0.040). No differences were seen in the OHP parameters. TEG® showed significant difference between marked and mild thrombocytopenia groups with minimal differences seen on CAT and OHP. Those with marked thrombocytopenia showed reduced maximum amplitude (47.2 vs 57.8 mm; P = 0.002) as expected while participants with mild thrombocytopenia (platelet count 100-150 × 109 /L) paradoxically demonstrated increased maximum amplitude (66.4 vs 57.8 mm; P < 0.001). CONCLUSION: Global coagulation assays, particularly TEG® , can detect subtle differences in coagulation in thrombocytopenic patients. While patients with marked thrombocytopenia showed reduced maximum amplitude, patients with mild thrombocytopenia appear to paradoxically show increased maximum amplitude, suggesting compensatory activity within the coagulation pathway which may in part explain why not all thrombocytopenic patients have bleeding complications.

The symptom burden of patients with hematological malignancy: a cross-sectional observational study.

CONTEXT: Current literature suggests that contact with specialist palliative care for patients diagnosed with hematological malignancy is infrequent. As part of an investigation into patterns of care, the symptom profile of this patient group required elucidation. OBJECTIVES: The purpose of this study was to determine the patterns of symptoms and level of distress in patients diagnosed with a hematological malignancy. METHODS: One hundred eighty patients diagnosed with a hematological malignancy attending a tertiary referral hospital completed the Memorial Symptom Assessment Scale-Short Form. Comparisons were made to published symptom prevalence studies of those with nonhematological malignancies. RESULTS: Patients with hematological malignancy had a considerable physical and psychological symptom burden, with an overall mean of 8.8 (± 5.9) symptoms. The mean number of symptoms was significantly greater in those on treatment (P<0.05), those with poorer performance status (P<0.001), inpatients (P<0.01), and those with a more advanced disease stage (P<0.001) than their respective counterparts. Symptom prevalence ranged from 69% for fatigue to 9% for vomiting. Global, physical, and psychological distress scores were high and varied significantly according to disease stage, Eastern Cooperative Oncology Group status, and patient location. The mean number of symptoms and level of distress were comparable to those patients with metastatic nonhematological malignancy. CONCLUSION: Patients with hematological malignancy are likely to have symptom control needs similar to those with metastatic cancer. Because such symptom burden appears to affect those at all phases of illness, comprehensive symptom assessment is suggested throughout. The introduction of palliative care services during times of increased symptom burden may assist hematologists and other carers in the management of their patients' distress and quality of life.

Palliative care and the hemato-oncological patient: can we live together? A review of the literature.

Current evidence suggests that patients with hematological malignancies less frequently access palliative care services, and for those who do, this tends to occur later in their illness than their counterparts with solid malignancies. These patients are also more likely to die in hospital following escalating interventions. This approach to care that considers palliative care referral after most treatments are exhausted has implications for the quality of palliative care intervention possible. An episodic approach engaging palliative care according to needs rather than prognosis may be more valuable. The successful integration of palliative care into the care of hemato-oncological patients requires recognition by palliative care physicians of the particular issues encountered in care, namely, the difficulty in individual prognostication; ongoing therapeutic goals of curability or long term survival; the technical nature and complications of treatment; the speed of change to a terminal event; the need for pathology testing and transfusion of blood products as death approaches; the potentially reversible nature of intercurrent events such as infection; and the long relationships that develop between patients and their hematologists. Meanwhile, hematologists should be aware of the benefits of palliative care earlier in an illness trajectory and that palliative care does not equate to terminal care only. This review summarizes current practices and barriers to referral, and suggests recommendations for collaborative care and further research in the palliation of hemato-oncological patients. In doing so, it highlights to palliative care and hematology physicians how successful integration of their disciplines may improve their care of these patients.