Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would testing for ATTR cardiac amyloidosis be considered in an older patient with bilateral carpal tunnel surgeries and multiple spinal stenosis surgeries, but no obvious cardiac symptoms?
I would not look for ATTR-CM in the absence of cardiac findings such as abnormal echo (increased LV thickness) or conduction abnormalities that are suggestive. Only 10% of patients with bilateral CTS have ATTR-CM. I would do an echo if not done and review ECG. As much as we are concerned about under...
How do you anticipate rusfertide will be used in the management of polycythemia vera?
Rusfertide, an injectable hepcidin mimetic (1), is another new arrow in the quiver of 21st-century therapies for controlling erythropoiesis without phlebotomy in polycythemia vera (PV), though likely to be replaced in the near future by gene silencing technology, which does not require as frequent d...
Are there different strategies you would utilize to monitor and manage potential resistance in patients with CML receiving asciminib?
Overall, I use similar monitoring strategies for all CML therapies, including what responses or loss of response prompt me to consider assessment for mutations that confer therapy resistance. Sometimes it is difficult to differentiate non-adherence vs emerging resistance, and thus it is important to...
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
What is your approach to persistently low INR despite escalating doses of warfarin in a patient with bioprosthetic mitral valve replacement who is unable to be on DOACs?
The assumption here is that the mitral valve is mechanical, or there are presumably other reasons that a DOAC cannot be used. If this is, in fact, a mechanical mitral valve, it would make sense to start with low molecular weight heparin injections as soon as feasible while awaiting a therapeutic INR...
Is there specific data on using luspatercept for sickle beta+ thalassemia with transfusion-dependent anemia?
There is no data currently on the use of luspatercept in any condition other than beta thalassemia, including HbE-beta thalassemia. It has been studied in the beta thalassemia phenotype, both transfusion-dependent and non-transfusion-dependent (adult data published, pediatric trial underway), but no...
Does 4G/5G polymorphism in the plasminogen activator inhibitor (PAI-1) gene increase the risk of thrombosis?
Venous thromboembolism (VTE) is a classical example of a multifactorial disorder where genetic and environmental factors interact to result in VTE. Of the genetic disorders, in isolation, many are weak risk factors but when combined with other genetic or one or more environmental risk factors increa...
Is there any benefit of using aspirin to mitigate VTE risk in testosterone-induced polycythemia?
Erythrocytosis is a common adverse effect of testosterone therapy, and results from several studies suggest an association between elevated hematocrit (Hct) and risk of VTE (Braekkan et al., PMID 19833630; Ory et al., PMID 35050717). There is currently no data to support the routine use of aspirin o...
What level of 24h urine M protein do you consider to define active myeloma in a patient with renal insufficiency, proteinuria and monoclonal gammopathy?
When in doubt, a renal biopsy is preferred to define what is the exact disease process leading to renal dysfunction. If cast nephropathy is seen, this supports a diagnosis of myeloma. If amyloid or light chain deposition disease is seen, this also supports a diagnosis of amyloidosis or MGRS/myeloma,...
How do you manage copper deficiency?
Copper supplements are available. Would need to exclude zinc excess as a cause and to discontinue zinc supplements.