Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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.
Do you check LDH levels for patients with CLL who are asymptomatic and on surveillance?
I personally include LDH as part of my routine chemistry panel monitoring of CLL in surveillance for several reasons. Often, patients with CLL can show up with new anemia; in such cases, the differential diagnosis is autoimmune hemolytic anemia versus disease progression. An elevated, new LDH level ...
Do you see a role for omidubicel upfront in severe aplastic anemia for patients without a matched donor?
We typically use cord blood products if there is no available family member donor or reasonably matched unrelated donor. The use of haploidentical family donors is very effective, less expensive, and allows supplementation with CD34+ stem cell boosts if counts are suboptimal DeZern et al., PMID 3234...
Do you consider bleeding risk in elderly, frail patients with atrial fibrillation to be similar for all NOACs?
I believe that apixaban carries a lower risk of bleeding, with particular reference to GI bleed, when compared to rivaroxaban and dabigatran. This is true in the population of AF patients at large and most probably in frail patients as well.
How do you manage catheter-associated, upper extremity superficial venous thrombosis?
I manage catheter-associated upper extremity superficial venous thrombosis (SVT) conservatively with arm elevation, warm compresses, NSAIDs, and topical creams containing NSAIDs. Upper extremity SVT is primarily caused by indwelling intravenous catheters, so I do strongly recommend catheter removal ...
How do you approach the risk/benefit discussion for IV iron in a patient with concomitant severe iron deficiency and elevated hematocrit due to supra-physiologic testosterone supplementation?
I only administer iron if symptomatic (pagophagia, RLS, etc). I have not seen iron deficiency with testosterone prior to phlebotomy. When it is required, I literally walk both sides of the aisle. If a non-phlebotomized patient presented with ID, I would work it up like any other. If I have to treat,...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
How long would you anticoagulate a patient with recurrent VTE who has ongoing risk factors for intracranial bleeding?
In general, my preferred agent outside of the inpatient setting in patients with a risk of intracranial bleeding is LMWH. In the inpatient setting, utilizing a bivalirudin or heparin gtt is most appropriate. I would monitor carefully, including potentially imaging 24 hours after the therapeutic anti...
Can AMPLIFY data be extrapolated to use of other BTKi's in combination with venetoclax or would you only ever use acalabrutinib/venetoclax in first line?
I prefer NOT to extrapolate results, given that BTKis have unique spectra of kinase activities ("kinomes"), different PK/PD properties (such as half life), different adherence rates and dosing schedules, and have different synergistic (especially in a complex immune context that we are committing to...