Severe, Refractory Primary Warm Autoimmune Hemolytic Anemia Requiring 90 Erythrocyte Transfusions.

A previously healthy 60-year-old man presented to the hospital with a hemoglobin of 3.5 g/dL. He was diagnosed with severe warm autoimmune hemolytic anemia (wAIHA) with reticulocytopenia on hospital day 1 that was not responsive to steroids, immune globulin, and rituximab. Over a 42-day hospital stay, the patient remained continuously transfusion-dependent with a ninety red cell unit requirement for his refractory disease. He was trialed on therapeutic plasma exchange before ultimately undergoing inpatient splenectomy that led to a response within hours. He remains in complete remission at six months of follow-up.

Marathon Runners' Knowledge and Strategies for Hydration.

OBJECTIVE: To study hydration plans and understanding of exercise-associated hyponatremia (EAH) among current marathon runners. DESIGN: Cross-sectional study. SETTING: Southern California 2018 summer marathon. PARTICIPANTS: Two hundred ten marathon runners. INTERVENTIONS: Survey administered 1 to 2 days before the race. Race times were obtained from public race website. MAIN OUTCOME MEASURES: Planned frequency of hydration; awareness of, understanding of, and preventative strategies for dehydration and EAH; resources used to create hydration plans; drink preferences. RESULTS: When the participants were split into 3 equal groups by racing speed, the slower tertile intended to drink at every mile/station (60%), whereas the faster tertile preferred to drink every other mile or less often (60%), although not statistically significant. Most runners (84%) claimed awareness of EAH, but only 32% could list a symptom of the condition. Both experienced marathoners and the faster tertile significantly had greater understanding of hyponatremia compared with first-time marathoners and the slower tertile, respectively. Less than 5% of marathoners offered "drink to thirst" as a prevention strategy for dehydration or EAH. CONCLUSION: Slower runners plan to drink larger volumes compared with their faster counterparts. Both slower and first-time marathoners significantly lacked understanding of EAH. These groups have plans and knowledge that may put them at higher risk for developing EAH. Most marathon runners did not know of the guidelines to "drink to thirst," suggesting the 2015 EAH Consensus statement may not have had the desired impact.