hematology

What Not to Wear In the Hospital While Recovering From a Stroke

Today’s Annals of Internal Medicine includes new results for the CLOTS (Clots in Legs Or sTockings after Stroke) Trial. Not-quite acronyms aside, it’s an interesting study with implications for many patients at risk for deep venous thrombosis (DVT).

compression stockings - NIH image (Medline Plus)

This U.K.-based study, involving 3114 patients in 112 hospitals in 9 countries, used ultrasound to evaluate possible DVTs in legs of people after they’d been immobilized upon suffering strokes. Patients were randomized to receive either thigh-length or below-the-knee compression stockings while recovering in the hospital. The main result was that 98 of 1552 (6.3 %) of patients who received thigh-length stocking and 138 of 1562 (8.8%) of patients with below-the-knee stockings developed DVT. This difference is highly significant (p = 0.008).

The twist is this: in a separate, extensive recent Cochrane review the investigators compiled data from multiple randomized studies of stockings in stroke patients and established that thigh-length stockings were inferior to no stockings, i.e. stroke patients who wore thigh-high compression stockings were more likely to develop DVTs than those who didn’t wear any stockings at all. The authors reconcile these separate results by suggesting that below-knee stockings might increase the risk for DVT after stroke.

Confusing? Yes. The bottom line is that thigh-high compression stockings may not help, based on the Cochrane analysis; below-the knee stockings may hurt.

Why this matters is that the results have implications for other hospitalized patients at risk for DVT, like people who’ve had hip replacements, pelvic or spine surgery. “Unfortunately, no randomized trials have compared below-knee stockings with no stockings,” the authors write.

An accompanying editorial in the Annals considers the “puzzling” findings of the CLOTS trials and addresses how clinicians might prevent DVT in patients with stroke:

…The unexpected findings that thigh-length stockings are not very effective at preventing venous thromboembolism and that below-knee stockings might increase incidence of thrombosis in patients with stroke should prompt a reevaluation of the role of graduated compression stockings in other groups of patients….Clinicians need to realize that despite the ubiquity of graduated compression stockings in many settings, the net benefits and risks of this seemingly innocuous intervention remain uncertain.

As a hematologist, I see this as a low-tech, big deal because DVTs are a huge source of morbidity and mortality.

In the U.S., the number of clots per year runs in the hundreds of thousands. DVTs tend to arise in people who are immobilized after surgery, with neurological impairment and during travel. The elderly are particularly susceptible, as are pregnant women and people with inherited clotting dispositions. The National Blood Clot Alliance provides an interactive map of the incidence of DVTs, state by state, on its website.

Personally, I love it when the doctors allow me to take off the boots when I wake up after a procedure, so I can kick my feet around and, I hope, reduce my risk of DVT by movement and exercise. Compression stockings feel like corsets on my calves; they’re warm and constraining. On planes, too; I find stockings restrictive.

My own experience aside – the data supporting the use of compression stockings are limited, and this new study suggests they can be damaging.

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A Lead Poisoning Outbreak in Nigeria, Plumbism and Anemia

Over 400 Nigerian children have died from lead poisoning this year, the Times reported yesterday. The outbreak is centered in five villages in the northwestern state of Zamfara.

Small-scale gold mining in the region leads to lead toxicity, as follows: “In an attempt to extract gold from ore rich with lead, miners crush and dry the ore, often inside their own homes. The soil and in some cases the groundwater get contaminated,” according to an Oct 5 field report from Doctors Without Borders/Médecins Sans Frontières (MSF).

I learned long ago that lead poisoning is sometimes called plumbism, stemming from plumbum, the Latin term for lead (Pb, atomic number 82), a metal used by plumbers. A rarer term is Saturnism, based on the metal’s association with the planet and ancient Roman god.

Now, in the U.S., lead poisoning most commonly comes from environmental toxins like lead-based paint. It affects children, who may eat flakes of peeling, lead-based paint or accidentally ingest lead by licking or eating toys or jewelry that contain this toxic metal. The problem occurs in adults, too, typically from unknown sources.

The EPA provides some helpful information on its website. Lead poisoning can be subtle; common symptoms are fatigue and poor concentration. Doctors may detect anemia, and upon inspection of a patient’s red blood cells might find characteristic basophilic stippling. The National Institute of Environmental Health Sciences (NIEHS) reports that lead toxicity declined dramatically from 1980 to 2000 in the U.S.

lead poisoning; arrows point to characteristic basophilic stippling (attr: Herbert L. Fred, MD and Hendrik A. van Dijk, Wikimedia Commons)

In northwest Nigeria, MSF workers are treating some of the affected children and nursing mothers with chelating agents; these metal-binding compounds clear lead from the bloodstream and, to some extent, remove it from body organs where it’s already deposited. The World Health Organization (WHO) issued a bulletin on lead poisoning from gold-mining in Nigeria in June, 2010.

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Perspective on Screening for Sickle Cell Trait in Student Athletes

Today I watched a video, The Student-Athlete with the Sickle Cell Trait, sponsored by the National Collegiate Athletic Association (NCAA) on its website. The 12-minute presentation provides some helpful background on what it means to have sickle cell trait and how awareness of that condition might influence a student’s (or coach’s?) behavior during rigorous conditioning and competitive sports.

“The more medical information we know about our student athletes, the better equipped we are to help keep them safe,” says Mark Richt, Head Coach at the University of Georgia, at around 3 minutes into the clip.

A new NCAA policy mandates screening all Division I college sports participants for sickle cell trait. Not coincidentally, the Sept 9 issue of the New England Journal of Medicine opens with a noteworthy perspective* on this topic. The screening recommendation, effective at the start of this academic year (i.e. now) directly affects more than a few young adults in the U.S.: among nearly 170,000 athletes who’ll be tested this year, it’s expected that several hundred “carriers” will be identified.

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Avoiding Blood Clots During Long-Distance Travel

A few years ago my family took a trip to China. Even before we arrived, I learned something about an unfamiliar health care culture. What I observed en route was that many of the older passengers on that long flight to Beijing were getting up from their seats and stretching. Not just once, but regularly and systematically – they were doing slow motion, isometric calisthenics on the airplane.

I took notice of their behavior first because it seemed a simple and inexpensive, albeit strange example of preventive medicine. Second, as a hematologist who cared for patients with blood clots upon traveling, I pondered the risks and benefits of their on-board exercises. Third, as a patient who’s had a blood clot, or deep venous thrombosis (DVT), I thought maybe I should follow their example.

Thrombophlebitis – the old term for DVT – happens when a vein (as opposed to an artery) gets clogged with platelets and fibrous proteins. These tend to develop in people who are immobilized – after a hip or spine surgery, for example, or during long, cramped trips in airplanes with little legroom. For this reason, long-distance travel (in any sort of vehicle – it could be a car or bus or a train) is a major risk factor.

Dehydration and some medications can exacerbate the risk of developing blood clots during travel, as can having some kinds of cancer. (Pancreatic cancer, prostate, ovarian cancer and other tumors in the pelvis are particularly troublesome in this regard.) Some people inherit an increased tendency to develop clots; in general these can be evaluated by blood tests.

Most often DVTs arise in the legs but sometimes these also occur in the arms and other body parts. The condition can cause discomfort, pain, redness and swelling of an affected limb. These clots are most dangerous, and potentially lethal, if they spread to the lung – what’s called a pulmonary embolism. So there’s good reason to avoid these as best you can.

Here’s a list of some precautions to avoid blood clots when traveling:

1. Try to get an aisle seat. This strategy allows you to periodically stretch your legs into the aisle, and to get up without disturbing others.

2. While seated, move your feet and legs around as much as circumstances permit, and at least every hour or so. If you absolutely must remain seated, flex your feet 10 times, and stretch your legs as best you can, bending and extending the knees, one at a time, in any available direction, 10 times each. Another exercise is to raise each foot and swivel it, pivoting the toes from side to side while keeping the ankle relatively still.

3. Get up periodically and walk, every hour or two if permitted. (This means getting less sleep if you’re lucky enough to fall asleep, but I think the trade-off is worth it: being tired upon arrival is unpleasant; getting a blood clot is worse than that.)

If you’re on an airplane – once you’re up and out of your seat, seek out a place near the kitchen, restroom or elsewhere where you might stand. Then, hold onto the wall or the back of a chair, lift and stretch each of your legs repeatedly and then march in place: one knee up, then the next for two minutes or so, as conditions (and flight attendants) allow.

4. Stay well-hydrated by drinking ample water. Alcohol is a diuretic and should be avoided or minimized; caffeine too. Of course, for some travelers with weak bladders drinking lots of fluids can create a need for frequent bathroom trips. But this isn’t such a bad thing if you’re at risk for DVT, because this gets you up and out of your seat.

5. Dress sensibly – avoid tight clothing. (Some doctors recommend TED (thrombo-embolic Deterrent) or other compression stockings for patients with DVTs who travel, but I find these graduated compression nylons so uncomfortable that they reduce mobility, besides the capacity to bend and flex my ankles and knees.)

For women: avoid “knee-high” stockings with compression bands pressing just below the knees. These are a set-up for reduced blood flow from the lower legs to the larger, central veins.

6. Talk to your doctor if you’re concerned about DVT and are planning a trip. Ask about what precautions you might take in the context of your specific medical circumstances. Some people use heparin, a blood-thinner, or other medications while traveling to reduce their risk. Keep in mind that for most people, the risk of forming a significant blood clot is low.

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The trip to China was fabulous, well worth the distance.

More on travel next week –

ES

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Blood Matters

January, the coldest season in my vicinity, turns out to be National Blood Donor Month. This designation, a legacy of the Nixon administration (see Proclamation 3952 of December 31, 1969), I learned last week.

Besides, blood’s hot.

HBO’s True Blood received an invigorating, early renewal notice last summer; a third season will come out in June. And on film 2009 witnessed a quick, hungry revisit from Twilight, among others vampire flicks. Just this month, Ethan Hawke revealed himself in Daybreakers as Hollywood’s first hematologist-protagonist.

So it seems that now’s the perfect time to talk about it –

Blood, always my favorite Aristotelian humor, comprises two elements – plasma (a hazy yellowish fluid) and cells. The plasma bathes the blood cells in a mixture of salts and proteins as they travel within the walls of blood vessels throughout the body (the circulation) and in the chambers of the heart. Plasma proteins include some hormones, enzymes, clotting factors and antibodies.

Let’s start with some basics on the cellular components of blood: white blood cells, red blood cells and platelets:

neutrophil as seen in a peripheral blood smear, Wikimedia Commons (WC)

White Blood Cells

White blood cells (WBCs), physically larger than the rest, serve as warriors against infection. These include a cast of various types, each with a distinct role in battling germs. The most familiar white cells in the “peripheral blood” – as doctors refer to fluid passing through arteries and veins – are neutrophils, lymphocytes and monocytes. Two other forms, eosinophils and basophils, emerge from the bone marrow and typically travel in lesser numbers.

scanning micrograph, red blood cells, WC, adapted NIH image

Red Blood Cells

Red blood cells (RBCs), the most abundant and usually uniform blood cells, carry and deliver oxygen throughout the body. Mature, circulating red cells are disc-like in shape, indented on each side, and lack nuclei. They’re loaded with hemoglobin, a complex, iron-laden molecule that binds oxygen and turns blood red.

When someone receives a transfusion, that’s usually a unit of packed red blood cells, concentrated red cells from which most of the donor’s white cells, platelets and plasma have been removed.

Platelets

Platelets are tiny, blood clotting cells. Like red cells, these cells circulate without nuclei, but they’re irregular in shape and sticky, loaded inside with plug-forming proteins and on their surfaces with adhesive receptors, ready to clump at the nick of a chin or a pinprick.

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Both cancer and its treatments can affect the bone marrow, where blood cells are formed. Some tumors, like leukemia and lymphoma, arise from blood cells. Other medical conditions cause blood cell problems, too. For example, chronic kidney disease causes anemia, and HIV infection leads to reduced T-lymphocyte counts.

For all these reasons, I think it’s helpful for everyone to have some understanding of blood and blood cells – any discussion of stem cells, bone marrow and transplantation presupposes some knowledge of these basics.

More to follow!

Meanwhile, if you’re searching for more blood info on the Web, I suggest these sites:

American Society of Hematology – Blood: the Vital Connection

America’s Blood Centers – What is Blood?

American Society of Clinical Oncology (Cancer.Net) – Understanding Blood Test Results

MedlinePlus – Blood and Blood Disorders

National Heart Lung and Blood Institute – Blood Diseases and Resources Information

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Why Give Blood?

Giving blood is something that’s close to my heart.

When I was 14 years old, I received seven units of packed red blood cells from strangers during and after spinal surgery. In 2003 when an orthopedist bravely cut the steel rod fused to my spine, readjusted it and inserted new hardware, I got another four units. So I’m keenly aware of this mitzvah, of giving blood. It saves lives.

Today, thousands will donate blood to honor the birthday of Dr. Martin Luther King, Jr.

As a practicing hematologist through 2006, I wasn’t aware of this phenomenon. Over the past week, I’ve scoured blood journals, blood-banking websites and even contacted a few leaders in the field, but found few doctors familiar with the tradition or what’s at least a trend as tracked by the all-knowing Source:

Google search Timeline view (1-16-10)

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It’s not clear exactly when this practice, now seemingly integrated with nationwide MLK National Day of Service events, began. The Orlando Sentinel published an article linking blood donation with MLK on January 14 1988:

Florida Blood Services campaign image January 2010

Donors giving blood from 2 to 7 p.m. Monday at the American Red Cross center, 341 White St., Daytona Beach, will be donating in memory of Dr. Martin Luther King Jr.

Each person will sign a scroll saying they donated blood in King’s memory. That document will be presented to Bethune-Cookman College during a special assembly Wednesday, said JoAnn Lord, Red Cross spokesman.

In response to a similar blood drive, Coretta Scott King wrote: ”The national holiday is a time for personal recommittment to do something — to reach out to your brothers and sisters in the spirit of our common humanity. Certainly the giving of blood so that others may live is a very important way of committing yourself to others.”

Today I spoke with Daniel J. Eberts, corporate communications manager for the Florida Blood Services.  Dan’s been working with that agency for over 22 years. “The goal is to create awareness of the ongoing need for blood,” he says. The agency collects blood every day of the year except for Thanksgiving and Christmas, he notes.

“Dan the Bloodman” – as Eberts is sometimes called – is not shy in his passion for blood donation. Rather, he’s on YouTube, singing on how you, too, can give blood.

On recent MLK Days the Florida agency has collected between 500 and 700 pints of blood, he reports. The holiday presents a special opportunity to gather additional, much-needed minority registrants for the National Marrow Donor Registry.

Eberts emphasizes how easy it’s become to sign on as a potential donor. “All you need is some cheek swabs,” he says. “There’s no blood sample required. Now, most of the hassle is with the paperwork.”

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Here are some resources for people who’d like to know more about giving blood:

The American Red Cross provides information on when and where to donate blood, as well as helpful instruction on the process of giving for first-time donors.

The AABB, formerly the American Association of Blood Banks, covers transfusions and related therapies.

America’s Blood Centers – a large network of non-profit community blood centers.

The New York Blood Center – a terrific local resource for my neighbors, a pioneer in blood banking and resources for patients worldwide.

For those who’d consider bone marrow donation:

The National Marrow Donor Program helps patients with leukemia and other conditions find matching bone marrow donors.  The agency provides, also, financial assistance to some who can’t afford needed transplants.

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January is National Blood Donor Month. For those who can give, it’s never too late – the need is year-round.

And a personal note of thanks, from me!

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Moms Tweet About Blood and Cancer

This afternoon I found a Tweet from a colleague, a journalist who happens to be a mom in my community:

Tweet from SuSaw:

“RT @JenSinger: Hey, baby. What’s your blood type? Nothing against the Big Pink Machine… http://ow.ly/URkg

As a trained hematologist (blood doc), oncologist and breast cancer survivor, I couldn’t resist checking this out. Here’s what I discovered:

The link traces to MommaSaid.net. Turns out MammaBlogger Jen Singer counts herself among lymphoma survivors in remission. Another mom in remission, I might add –

Jen clues us in on a new breast cancer awareness campaign that migrated to Facebook but three days ago – breast cancer awareness ? I updated my Status with my Bra colour ? and, as of this moment, has over 57,000 fans. Her solidarity with breast cancer patients and their loved ones is very real. She’s at increased risk, among other reasons for her sensitivity to the issue.

Jen plugs for greater public consciousness of other malignancies including tumors that arise from blood cells – conditions like non-Hodgkin’s lymphoma, leukemia and myeloma. She’s particularly concerned about a young neighbor, a teenager with recurrent leukemia, who needs blood now.

In a post “O Positive is the New Pink” she writes:

“So, I ask you this: Please put your blood type in your Facebook status and ask your friends to do so, too, to raise awareness for lymphoma and leukemia. Mine is O+, a blood type…

I was blown away by this, and impressed. What social media might do for the practice of hematology!

With just a few clicks at the keyboard and some thousands of on-line connections, one lymphoma survivor has improved the chances that one girl with leukemia will get the platelets she needs. And, maybe thanks to the Facebook blood typing information campaign, more potential blood donors will connect with those who need cells in the future.

Last year, Phil Baumann listed 140 potential applications for Twitter in health care. I was curious but skeptical. Now I’m partly persuaded, at least.

Besides, just think what three moms can do. It takes a village…

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More soon – on giving blood, blood types and blood cells.

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Information Overload

Americans are consuming unprecedented amounts of information. Some small fraction of that – what we read, hear and see on TV – relates to health and illness. Today’s sources might include a story on cell phones and cancer, an NPR feature on autism or a commercial in which Sally Fields recommends Boniva, a drug for osteoporosis.

Does knowing more help us lead better, healthier lives?

In Bits, a NY Times blog on business, innovation, technology and society, Nick Bilton recently described our voracious appetite for enlightenment: 34 Gigabytes or, depending on how you count, nearly 12 hours’ worth of data-gleaning per day from diverse channels like television, radio, the Web, text messages and video games.

The Bits piece links to the Global Information Industry Center‘s “How Much Information?” (HMI?) project that issued a December 2009 paper. The research center, based at the University of California in San Diego, dates to 1960, when the Internet was, if anything, theoretical, and the concept of sharing computer-based data a matter of defense.

As best I can tell, the topics of “health” and “cancer” don’t figure prominently in the recent analysis. Maybe we don’t want to know much more on these subjects than we find in our doctors’ offices. But long runs of TV shows like “Marcus Welby, M.D.,” “ER” and “Scrubs” suggest otherwise. Indeed, many tune in regularly for a peek into the medical world, at least when fed in bits and pieces by idealized or heart-throb fictitious physicians with complex, warm and sometimes hot personal lives.

Nearly two-thirds of U.S. adults seek health-related information on the Web, says Susannah Fox of the Pew Research Center’s Internet & American Life Project. The agency tracks how North Americans use the Internet for medical purposes and published an update, “The Social Life of Health Information” earlier this year.

Dr. Kevin Pho touched on the issue in a December 16 post on KevinMD:

To be sure, doctors and other health professionals don’t get everything right. But anyone can find information on the web, which can be of dubious accuracy.

Knowing what to do with that data can only come with experience and training.

Fox, of the Pew Research Center, commented:

…one of our key findings is that most people use on-line health resources to supplement advice they get from doctors and other health professionals. After 10 years of researching this field, we have no evidence that the internet is replacing traditional sources of medical advice. Yes, many people are gathering and sharing health information online, but they are also discussing it with friends, family, and health professionals.

I was considering the matter last week, it happens, when I received an email from a former patient. He has hemochromatosis, an inherited disposition to iron overload. His body is programmed to take in excessive amounts of iron, which then might deposit in the liver, glands, heart and skin. He offered holiday greetings and mentioned “some amazing videos on hematology and hemochromatosis and genetics” he’d discovered on YouTube.

This is the future of medicine, I realized. A patient accesses public databases, videos and other resources to learn about signs and symptoms of his illness, what foods to eat or best avoid, what medicines and treatments he might need and if his condition is likely to affect others in his family.

Whether physicians want their patients to search the Internet for medical advice is beside the point. We’re there already, whether or not it’s good for us and whether what we find there is true.

The current issue is not about limiting non-professionals’ access to facts or fiction. Rather, it’s about how we might sift through so much material – whether that’s a CNN segment we take in, passively, while running on a treadmill in the gym, or a detailed analysis of a new prostate cancer treatment provided straight from an oncologist – and digest it properly.

Perhaps information is a bit like iron, an essential nutrient that makes us stronger. To benefit from such a surplus, we’ve got to somehow identify, process and absorb what’s useful, what helps and doesn’t hurt.

Patients using internet health information without physician guidance

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