Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you dose apixaban in patients with CrCl <30 mL/minute?
Patients with chronic kidney disease are challenging to treat with anticoagulation as they have an increased risk of both venous thromboembolism and bleeding. Treatment should be individualized after weighing the risks and benefits of anticoagulation as well as the indication for anticoagulation. Th...
How do you manage a patient with JAK2+ ET without history of thrombosis during pregnancy?
Great question. We've recently published our experience here How et al., PMID 33022566. Patients with ET that are pregnant and that don't have a history of thrombosis are likely to be in the very low/low risk categories by R-IPSET, many of these women are likely not on any treatment prior to startin...
What radiation treatment volume and dose would you deliver to an isolated DLBCL relapse in the left eye s/p vitrectomy and intraocular methotrexate?
This is a case of secondary ocular lymphoma but the management of primary ocular lymphoma may be helpful to consider. For patients with primary ocular lymphoma, a significant number of patients present with bilateral disease at initial diagnosis or will relapse in the contralateral eye after unilate...
Is prophylactic anticoagulation indicated in patients with frequent ulcerative colitis flares?
Background: We know that inflammatory bowel disease (IBD) is a risk for incident and recurrent venous thromboembolism (VTE). What is not clearly established is whether the IBD needs to be 'active' in order for it to be a risk factor, e.g. would patients who have had proctocolectomy (and perhaps no e...
Would you change an elderly, frail patient with atrial fibrillation who is already on a NOAC to VKA treatment?
I wouldn't on the basis of this study. Aside from the other limitations of the FRAIL-AF trial, this study only addressed the utility of switching a stable patient from VKA to NOAC and not vice versa. A patient who is doing well on an appropriately dosed NOAC may experience difficulty achieving adequ...
How do you manage concurrent non-life-threatening hemoptysis and acute pulmonary embolism?
Hemoptysis can occur with PE when there is pulmonary infarction. However, the majority of pulm embolism cases have pleuritic chest pain without infarction. Significant hemoptysis is very rare in these cases and anticoagulation is nearly always safe. When hemoptysis continues or the volume is concern...
What is your protocol for transitioning to oral anticoagulation post-thrombolysis for pulmonary embolism?
My answer has multiple parts."Thrombolysis" is not all the same. As studied in stroke treatment, alteplase causes marked fibrinogen depletion and coagulopathy (prolonged PT, aPTT), whereas tenecteplase doesn't so much (Huang et al., PMID 26514192).So, if alteplase was used (systemic or reduced cathe...
When would you initiate chronic therapeutic phlebotomy in a patient with erythrocytosis secondary to a high hemoglobin-oxygen affinity hemoglobinopathy?
The large majority of patients with high oxygen affinity hemoglobinopathy do not require therapeutic phlebotomy. There is a subset of patients who develop symptoms (generally these are non-specific such as headache) or complications such as thrombosis. There seems to be no correlation between hemato...
Do you recommend lifelong antibiotic prophylaxis, or do you prefer a more selective approach based on risk factors in asplenic patients without a history of severe infections?
The advice is limited by the fact that there are no randomized controlled trials in adults on daily antibiotic prophylaxis post-splenectomy. There are trials in children with sickle-cell disease that do show a benefit, but it is not clear that these can be extrapolated to splenectomized adults. Furt...
Would you consider elective neck nodal irradiation for a large >5 cm head and neck extramedullary solitary plasmacytoma arising from the nasal cavity?
A plasmocytoma in the nasal cavity may bear a higher risk for nodal involvement if it involves Waldeyer's ring or nasopharynx.Adding ENI to the neck will certainly increase the risk of toxicity and only lead to a modest benefit in terms of isolated regional recurrence. I would thus not perform elect...