Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How often do you utilize soluble transferrin receptor or hepcidin testing in the diagnosis of ambiguous iron deficiency, such as with concomitant anemia of chronic disease?
Almost never. While the soluble transferrin receptor and serum hepcidin levels may provide useful information, their lack of ready availability and costs makes them inconvenient and inefficient as a standard. There is no evidence extant that either offers an advantage to the TSAT. All of this is a m...
What is your approach to a patient with positive antiphospholipid antibodies who otherwise do not meet clinical criteria for APS?
As antiphospholipid antibodies constitute a diagnostic criterion of SLE, such patients may need to be evaluated and monitored long term for both SLE and APS.
Is there a role for radiation therapy in the treatment of a lymphoproliferative disorder involving the orbit?
When I don't have pathology/flow/PCR reports diagnostic of malignancy, I have treated patients with "lymphoid atypia", "atypical lymphoid infiltrate", or "lymphoproliferative disorder" with symptomatic disease to 4 Gy in 2 fractions. I have a collection of such patients (about a dozen), almost all o...
How do you approach treatment in a patient with a solitary plasmacytoma with minimal marrow involvement (< 10% clonal plasma cells)?
Solitary plasmacytoma with minimal bone marrow involvement is a confusing entity as even the name seems somewhat contradictory--it is indicating there is a solitary lesion but at the same time indicating that there is systemic involvement (i.e., bone marrow involvement by clonal plasma cells). It is...
What is the transfusion management of a sickle cell patient during pregnancy?
Prophylaxis: There is an ongoing trial in transfusion management in pregnancy, comparing prophylactic red cell exchange to a target HbS or SC < 30% compared to transfusion only when clinically indicated. Interestingly, it does not specify a Hct target. Until that trial is done, I would follow the AS...
How would you approach the treatment of patients with von Willebrand disease or hemophilia A previously managed with intranasal DDAVP during the recall?
There are two separate questions here, one is easy and one complicated. Desmopressin challenges can be performed with intravenous desmopressin, 0.3 mcg/kg. It is not necessary to challenge a patient with IV who previously responded well to the nasal preparation, in my view. How to approach treatme...
Is antiplatelet or anticoagulant therapy preferred for the secondary prophylaxis of cryptogenic stroke in a patient with underlying malignancy?
Will look at the stroke radiographically. If appears embolic and the patient is low risk for bleeding, with respect to their cancer regimen, co-morbidities, and labs, I will discuss off-label anticoagulation with eliquis. If there are additional, chronic embolic appearing strokes - that will also sw...
For a patient with previously relapsed TTP but in clinical remission, what is the role of rituximab in treating asymptomatic ADAMTS13 deficiency to prevent relapse?
A very good and interesting question. In remission, there is no question that severely deficient ADAMTS13 activity (<10%) is a strong risk factor for relapse. In patients with a chronic relapsing TTP history (at least 2 episodes), the approach most commonly has been to treat them preemptively with r...
How would you treat an adult patient with T-cell lymphoblastic lymphoma with FGFR1 rearrangement and co-exisiting myeloproliferative neoplasm?
This is a rare condition only recently recognized as its own diagnostic entity by the WHO as part of a larger family of disorders referred to not-concisely as "myeloid/lymphoid neoplasms associated with eosinophilia and rearrangement of PDGFRA, PDGFRB, or FGFR1 or with PCM1-JAK2" (Arber et al., PMID...
When would you perform a thrombophilia workup in a pediatric patient presenting with VTE?
I was trained to do workup in cases of unprovoked VTE and still practice that way mainly to guide the length of anticoagulation therapy as well as prophylaxis. I must admit though, in pediatrics I have come to realize there is more practice based on experience and extrapolation from adult data than ...