Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Do you offer IV iron first line to women with iron deficiency anemia from heavy menstrual bleeding?
I offer first-line IV iron because oral iron cannot keep up with the losses from heavy menstrual bleeding, and the majority can't tolerate it. I routinely give a gram of LMW iron dextran in one hour, Feraheme (not ferumoxytol generic) 1,020 mg in 30 minutes, or ferric derisomaltose 1 gram in 30 minu...
Is there benefit to aggressively treating hemochromatosis in a patient who has already progressed to cirrhosis at the time of diagnosis?
The short answer is yes, there is a benefit to treating iron overload in a patient with hereditary hemochromatosis (HH) with cirrhosis. HH involves at least five mutations, most commonly in the HFE gene (common variants include C282Y and H63D), leading to hyperabsorption of iron and progressive accu...
What screening tools or signs do you use to predict if a cancer patient is near end-of-life?
For most of us, long-time practicing oncologists, all we have to do to determine that one of our patients is at the end of their life is to be in the same room with them. No special computer programs or calculators are needed. Just look closely at the patient's current weight, their level of conscio...
Do you do prophylactic LP/IT chemotherapy in high risk APML prior to starting consolidation?
Extramedullary disease such as CNS involvement is quite uncommon at diagnosis in acute promyelocytic leukemia (APL). However, it can be seen in patients with relapsed disease. Both isolated CNS relapse and CNS relapse associated with morphologic or molecular relapse can occur. Yet one has the impres...
What dose of radiotherapy do you use for low volume Castleman's disease?
Reports in the literature are varied in terms of radiation dose. For scenarios such as this with low volume disease, it is probably reasonable to consider the lower end of ranges reported by others to be successful, such as 30 Gy. Careful pathology review is important for these cases as well. One mu...
Do you check IGHV mutation status in patients with newly diagnosed CLL?
Yes. In the targeted therapy era, there are three factors that continue to have prognostic and therapeutic significance and should be checked: IgHV mutation status p53 aberrancy - requires both FISH for del17p AND mutation analysis for p53 Complex karyotype - can be done on peripheral blood or marr...
Has your practice changed to PLEX-free initial therapy for iTTP?
I am not. The reason is that caplacizumab is not on formulary at my institution, and so implementing PLEX rapidly while obtaining caplacizumab (which typically arrives in 24-48 hours) is my current practice. If I had caplacizumab on formulary, I would utilize it as it was utilized in the MAYARI tria...
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...
Would you radiate the thoracic duct for bilateral chylothorax in a hematologic malignancy with no discrete adenopathy?
We have done for adenopathy, which relieves obstruction and thus helps with drainage, but we don’t know how it would help in this situation.
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...