Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your approach to bone imaging in MGUS?
Excellent question. For low-risk MGUS (M-spike <1.5 g/dL, normal serum free light chain ratio, and an IgG type protein), it is reasonable to forego any bone imaging in the absence of any relevant bone-related symptoms. The rate of bone involvement in patients with an M-spike of 1.5 g/dL was noted to...
Would you supplement iron for low iron studies in absence of anemia?
The answer is absolutely and positively. Iron deficiency causes symptoms independent of anemia which include fatigue, brain fog, restless legs syndrome, and pagophagia and other forms of pica. You simply cannot dignify waiting for overt iron deficiency to develop in someone with symptomatic iron def...
How do you approach the management of a patient with symptomatic iron deficiency anemia who is intolerant of iron?
Oral iron will not work. I would bet my last dollar there was no anaphylaxis but rather an imprudently treated minor infusion reaction which is the cause of ostensible “anaphylaxis” over 99% of the time. You can’t verify that it was real because I can assure you: It was not. They did not do a trypt...
Do you routinely refer young patients with iron deficiency anemia for GI evaluation?
The answer is no, I do not. However, if after iron repletion deficiency persists, then I do. But as for pregnancy, unless there has been a precipitous and proven drop, I would definitely not do a GI workup during pregnancy.
How would you manage symptomatic iron deficiency in patients with PV on frequent phlebotomies?
While iron deficiency by itself is not harmful, if someone has symptomatic iron deficiency, you could consider them intolerant to phlebotomies, and start a cytoreductive agent. Then, over time they can replete their iron stores. In some patients who are very symptomatic from their iron deficiency, I...
How soon after initiating oral anticoagulation therapy for atrial fibrillation can it be interrupted for surgery or procedures?
As with most things medical, multiple answers. If a patient walks into my office for preOp "clearance" and behold, they are in atrial fib, but asymptomatic, then it would depend on the urgency of their surgery. If elective, then you have time to work up his atrial fib and look for a reversal cause (...
For a patient with May-Thurner syndrome and DVT, would you recommend anticoagulation for 3-6 months or indefinitely?
This is a very good question, there is little data on this and there are only a few case series. One case series of 8 patients showed a 25% risk of recurrence in one year with May-Thurner syndrome but too small of a sample to really know what the risk is, plus this probably included a heterogenous m...
For patients with newly diagnosed VTE on IV heparin planned for transition to DOAC, would you start at the loading or maintenance DOAC dose?
Agree with Dr. @Dr. First Last. In the clinical trials that led to rivaroxaban and apixaban approval, many patients had 2 days of injected anticoagulant first to arrive at successful outcomes leading to DOAC approval. I suggest IV heparin until hemodynamically normal (for PE), sq LMWH for a dose or ...
How are you deciding between available third line therapies for post-transplant relapsed DLBCL?
If a patient relapses after an autologous stem cell transplant and is a candidate for CAR T-cell therapy, I would proceed with CAR T-cell therapy given longer follow up compared to bispecific antibodies, and thus a portion of the patient can achieve a durable complete response. For patients that rel...
How does your surveillance for DLBCL change given the new role of CAR-T in 2nd line treatment?
There were at least 2 large studies from Europe showing that surveillance imaging for lymphoma patients in remission after completion of upfront treatments don’t improve survival (regardless of histology). I don’t usually get any imaging for DLBCL in remission after the end of treatment imaging. Pos...