Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Are there specific findings that would make you suspicious of IgD or IgE monoclonal gammopathies?
I mostly consider an IgD or IgE monoclonal gammopathy in a patient who has a measurable serum M-spike on serum protein electrophoresis but a serum immunofixation that only shows a light chain band (either kappa or lambda). Since patients with light chain-only myeloma usually have at most a tiny mono...
How long would you anticoagulate for PE developed after air travel in a woman on an estrogen-containing vaginal ring for contraception?
This patient has two transient (“provoking”) factors that may have contributed to her pulmonary embolism (PE): the use of estrogen-containing contraception and, presumably, a recent long-haul air travel. Traditionally, it has been assumed that, after three months of treatment for the initial venous ...
Are there instances where you can defer on mass spectrometry testing for amyloid typing in Congo Red positive tissue?
This is a great question and one that is not uniform in its answer depending on the clinical situation.Assuming we are talking about at diagnosis here, the short answer is always send Congo red positive bone marrow findings for mass spec typing if there is enough positive protein to dissect and type...
How do you follow pulmonary embolism patients who have completed anticoagulation?
3 months after sustaining an acute PE, I asked the patients if they were back to their pre-PE level of functional capacity. If they are not, i.e. if they remain dyspneic, I get an echocardiogram and a VQ scan. If the echo during the acute PE shows RV strain or evidence of pulmonary hypertension, I r...
Regarding CVST, what protocol of heparin dosing do you regularly use and does it change depending on clot burden/ICH status?
There is very limited randomized evidence for the use of anticoagulation in any form for CVST. We often rely on extrapolations from data on the acute management of DVT in the leg and pulmonary embolus. We are mainly limited to cohort studies and small RCTs. Recent trials in this area include the TO-...
Would you consider long term avatrombopag use in patients with cirrhosis requiring higher platelet counts for medical therapy?
In general, no, I would not use long-term avatrombopag in patients with cirrhosis requiring higher platelet counts for medical therapy due to the perceived thrombotic risk and hemostatic abnormalities of patients with liver disease.One thing to note in assessing the risk of long-term TPO mimetic the...
What is your recommended long term management of extensive dural venous sinus thrombosis in an otherwise healthy young patient?
From a Vascular Neurology perspective, there are two considerations when faced with patients with venous sinus thrombosis. First is the status of the intracranial venous circulation and whether or not there has been adequate reconstitution of venous outflow, either through recanalization or collater...
How would you structure your monitoring for a low-risk leukemic TP53-negative mantle cell lymphoma with 5% MCL cells detected in both peripheral blood and bone marrow, mild splenomegaly, and no lymphadenopathy or B symptoms?
This appears to be the prototypical indolent patient for whom observation would be ideal. For these patients, there isn’t a truly validated period of monitoring. I have typically extrapolated from follow-up from other chronic diseases, with a plan to extend follow-up intervals over several years. In...
Do you use direct oral anticoagulants to treat port-a-cath related VTE in patients with an active malignancy?
The initial trials that established DOACs as effective and safe in most patients with cancer-associated thrombosis (Agnelli et al., PMID 32223112, Planquette et al., PMID 34627853) only included patients with lower-extremity DVT or PE but clearly showed equivalence to low-molecular weight heparin (w...
Do you screen for VWD in all women with menorrhagia severe enough to cause iron deficiency anemia?
Yes, testing vWF is needed in this situation of severe menometrorrhagia. Excessive menstrual bleeding, especially when severe enough to cause anemia, is a common presenting symptom of vWD in women. The testing should be done as part of a comprehensive workup for gynecologic etiologies and other coag...