Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you manage perioperative anticoagulation for a patient with a history of recent, surgically provoked VTE?
In most cases, bridging is rarely indicated because the bleeding risk usually outweighs the risk of VTE recurrence during a short (1–2 day) interruption of anticoagulation. However, after a recent VTE (defined as <3 months), the estimated risk of VTE recurrence is high (>15–20% per year) (still low ...
How would you approach a patient with vitreoretinal lymphoma without CNS or systemic involvement?
The optimal treatment approach for primary intraocular lymphoma is debated. This is a rare disease with only small retrospective series guiding therapy. There is no clear superior treatment approach in the literature. In clinical practice, younger patients are often treated initially with high-dose ...
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.
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.
What are the best labs to trend improvement in HLH?
Unfortunately, there is not one specific laboratory test to definitively trend responses to HLH directed therapy. In general, our approach is to obtain baseline inflammatory labs including CBC with differential, ferritin, soluble IL2 receptor (sIL2r), triglycerides, coagulation studies (PT/PTT) incl...
Would you offer live vaccines (e.g., MMRV/measles) to patients on bispecific antibodies for multiple myeloma?
I agree with the answer here by Dr. @Dr. First Last. There are a lot of nuances, though. In regard to giving the vaccine safely and effectively, the best strategy is not to wait until patients have multiple relapses and are on bispecific therapy to vaccinate. Given the recent outbreaks of measles, i...
How do you approach initial anticoagulant selection in hemodynamically stable hospitalized patients with newly diagnosed pulmonary embolism?
Low-molecular-weight heparin demonstrates the greatest benefit in patients with cancer-associated pulmonary embolism, intermediate-risk PE, and those requiring outpatient management. While LMWH shows superior efficacy and safety compared to unfractionated heparin across most patient populations, cer...
For transplant-ineligible aplastic anemia planned for immunosuppression, how do you approach duration and tapering of cyclosporine and eltrombopag?
One of the most common mistakes in the management of AA is premature tapering of cyclosporine or tacrolimus. If there is a complete remission, and by that I mean normalization of counts, not complete remission as defined in some papers (e.g., ANC 1000, Plts 100,000, Hb 10 as in de Latour et al., PMI...