Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you approach hormone replacement therapy for perimenopause in a patient with increased risk factors for VTE?
Like many medical choices, this decision involves weighing trade-offs—specifically, the risk of venous thromboembolism (VTE) versus the burden of severe menopausal symptoms. If we focus only on VTE risk (and set aside the trade-offs related to menopausal symptoms and the controversial issue of breas...
How do you approach laboratory assessment for anticoagulation adherence when working up anticoagulation failure?
When faced with an anticoagulation failure, my go-to test for adherence is looking at the medication-dispense report (if you have this available at your institution, it is very handy for understanding the patient's adherence to anticoagulation). Typically, this will either show intermittent dispensi...
What is the best way to prepare children with von Willebrand disease for tonsillectomy to reduce the risk of post-operative hemorrhage?
I am an adult provider, but the treatment is similar regardless of age. The exact treatment plan will vary depending on the type and severity of VWD (i.e., mild type 1 VWD vs type 2B VWD); however, for tonsillectomies, I provide VWF concentrate 40-80 IU/kg 5-30 min preoperatively, followed by postop...
How long would you anticoagulate for a catheter associated DVT in pregnancy?
Available guidelines for management of catheter-related DVT, including the 2012 ACCP CHEST guidelines, typically recommend 3 months of anticoagulation if the central venous catheter (CVC) is removed. In those who require ongoing CVC placement, which is common in patients with cancer requiring system...
How often do you check weight and adjust anticoagulation dosing in pregnancy?
In patients on prophylactic or intermediate doses of Lovenox (e.g., 1 mg/kg once daily), I do not adjust the dose during pregnancy. (Although this "intermediate-dose" approach is not supported by the Highlow trial, I will use 1 mg/kg daily in a woman with a more extensive clotting history—such as a ...
For patients with intermediate or lower risk essential thrombocythemia with plt >1000 but no symptoms, do you favor aspirin only therapy or aspirin and cytoreduction?
First, the wrong question is being asked. The correct question is, what is the proof that the low-risk, intermediate-risk, or high-risk ET classification has any validity? My answer would be that this classification has no validity. Whether it is based on the IPSET scoring system or one of the other...
Do you consider thrombocytopenia a contraindication for fibrinolytic therapy for a massive PE?
If one has access to mechanical thrombectomy devices and operators, they should be considered before systemic thrombolytics unless the massive PE is causing imminent danger to the patient/patient is going to code/die, in which case the risk of dying from said PE is higher than potential bleeding eve...
What is your target Hgb/Hct for women who are pregnant and have sickle cell disease in whom you are doing scheduled transfusions?
Hg 10-11. My main goal is to suppress reticulocytosis and therefore, the production of more sickled cells.
In a patient with negative Hep B surface Ag, Hep B surface antibody+, and Hep B core antibody+ serologies, do you initiate antiviral prophylaxis (e.g. entecavir) prior to starting rituximab?
I would use entecavir for Hep B reactivation prophylaxis in this case - based on recommendations from AGA 2025 guidelines, which does classify b-cell depleting agents as higher risk for reactivation for both Hep B surface Ag-positive and Hep B surface Antigen neg/core positive patients. It should be...
In what clinical scenario would you consider liver transplant evaluation for a patient with sickle cell hepatopathy?
We have evaluated and transplanted patients with sickle cell hepatopathy with severe liver dysfunction but well-controlled sickle cell. These patients will typically have jaundice, coagulopathy, and biliary strictures. They should not have significant extrahepatic complications of the hematologic di...