Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you manage hyperhemolysis syndrome in a patient with life-threatening anemia and evidence of end-organ ischemia who requires emergent transfusion despite the risk of worsening hemolysis?
Any sudden-onset, rapid hemolysis could be encompassed by the term hyperhemolysis, for instance, following a mismatched transfusion, a delayed hemolytic transfusion reaction (DHTR), hemolysis triggered by an autoantibody, or a toxin in someone with G6PD deficiency or an infection in someone with sph...
In what scenarios do you use a chromogenic factor X assay in adjusting INR goals for patients on warfarin?
I do not use this method. It has been suggested that such assays be used in patients with lupus-type inhibitors who have significantly prolonged prothrombin times at baseline. In this setting, if the INR is "therapeutic," one would confirm an adequate warfarin effect if the factor X activity was in ...
What is your approach to the management of unprovoked distal DVTs?
The management of distal deep vein thrombosis (DVT)—[involving the peroneal, posterior tibial, anterior tibial, or the muscular calf veins (gastrocnemius and soleus); proximal DVT, by contrast, refers to thrombosis in the popliteal, femoral, or iliac veins]—is evolving in step with broader changes i...
Do you attempt treatment breaks from bispecific antibody therapy in patients with relapsed myeloma who achieve a sustained MRD-negative complete response?
I don't attempt to stop therapy in people who achieve deep responses and are tolerating the drug, but this is mostly because there is currently a paucity of prospective trials, so the specific time at which stopping therapy is optimal has not been established. I do have a low threshold to space out ...
How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?
I would certainly treat the ITP with hematology involvement if necessary but would continue to monitor for lupus or similar CTDs. I have seen patients present with an ITP-like picture for years before lupus declared itself eventually. It may take years. I would also check a UA for proteinuria. This ...
For a patient with lenalidomide-refractory R/R multiple myeloma at first or second relapse, how would MeziKd (if approved based on SUCCESSOR-2) factor into your sequencing decision relative to BCMA-directed and other available options?
There is never a good time to be a myeloma patient, but this is the best time it has ever been.Tldr; I would still prefer a BCMA-directed strategy for patients with BCMA-naive relapsed MM.The recently reported results of the phase 3 SUCCESSOR-2 trial demonstrated the efficacy of mezigdomide, a novel...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
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...
What is the utility of a hypercoagulability workup in recurrent cryptogenic stroke, and what specific tests would you recommend?
Ambulatory monitoring for AFib is probably more helpful than such a thorough clotting workup.
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
This happens all the time now. I tell them that those results were flagged as outside the reference range (I don't use the term abnormal) but that they are not clinically significant. It does not always work if there is a patient who is super anxious or hyper-focused. Typically, if they need a lot m...