Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
When would you phlebotomize patients with secondary hemochromatosis, such as due to NAFLD/cirrhosis?
My simple answer is “rarely, if ever” (but it can get much more complicated). Related to hepcidin changes, patients with chronic liver disease frequently have elevated serum ferritin and transferrin saturation, more so with alcoholic liver disease and non-alcoholic fatty liver disease. It is far fro...
How would you treat AML in a pregnant patient at 12 weeks' gestation?
My answer is under the assumption that, after a multi-disciplinary discussion with the patient, oncology/leukemia team, and maternal fetal medicine, the objective is to initiate AML-directed therapy while maintaining the pregnancy. The highest risk of deleterious impact to the fetus from chemotherap...
How do you treat factor XI deficient patients with surgery or trauma related bleeding?
Given the risk of elevated plasminogen with low FXI, prefer FFP, with fibrinolytic if mucosal bleeding.
What is your approach to utilizing MRD-guided therapy in previously untreated CLL, particularly in choosing between continuous versus time-limited treatment?
The question of what to do relative to a patient receiving therapy for CLL in first line and being MRD negative in blood/bone marrow with a reliable test (NGS sequencing or high sensitivity flow cytometry) and also no enlarged lymph nodes on CT/exam greater than 1.5 cm is challenging. For ibrutinib ...
For iron deficiency anemia due to heavy menstrual bleeding, what is your preferred method of controlling heavy menses?
I definitely loop in my GYN friends for this one! According to ACOG: "Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman's physical, social, emotional, or material quality of life." The consequences of HMB are substantial and multifaceted, and, as we f...
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
How do you manage erythrocytosis secondary to sotatercept for patients with PAH?
I have not done that yet, but I have let Hgb drift up to 18-19 and monitor the patient closely. I lower the dose to 0.5 or even 0.3, if Hgb is high at baseline, then start and stay at 0.3 before I increase. I will consider phlebotomy if the above options are not available.
Do you routinely evaluate patients with collagen disorders or Ehlers-Danlos for platelet defects?
Yes, I routinely carry out a full hemostasis evaluation, including platelet aggregation and release studies, in patients referred to me with easy bruising and hypermobility with an increased Beighton score suggesting EDS and in those already diagnosed genetically with EDS. EDS patients typically hav...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...