Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Do you avoid ESA use in patients with anemia and chronic kidney disease who also have APLS and risk for thrombosis?
I normally don't. I would make sure the patient is getting anticoagulated if indicated. I don't believe making the hemoglobin closer to normal in the setting of being anticoagulated increases thrombosis risk that much. I would shoot for a hemoglobin goal of 10-11.
What is your approach to treating limited stage DLBCL of the colon?
Often times patients with CSIE DLBCL of the colon will receive the diagnosis after a hemicolectomy intended to treat presumed colon adenocarcinoma. In such cases, I will routinely offer short-course chemotherapy consolidaton (3 cycles of RCHOP chemotherapy, most commonly; R-da-EPOCH can be considere...
How do you approach management for CCUS with severe cytopenias?
This is a very timely question since CCUS is now much better defined. CCUS (Clonal cytopenia of undetermined significance) is not a new syndrome, it is a subset of myelodysplasia (MDS), both of which as late as 1983, were actually known as: "Preleukemia". CCUS is an uncommon form of MDS, which has v...
How long post operatively do you wait before transitioning from parenteral anticoagulation to oral anticoagulants after pulmonary thromboendarterectomy for CTEPH?
It depends. In straightforward cases, we are pretty aggressive with starting anticoagulation to prevent re-thrombosis after pulmonary thromboendarterectomy. These patients are started on parenteral anticoagulation (with IV heparin) on POD #0, usually within several hours after arriving in the ICU if...
What is the preferred approach to managing non-occlusive or partially occlusive venous sinus thrombosis?
I would recommend a DOAC, particularly apixaban, with follow-up imaging in 3 months.
How do you manage a patient with low risk MDS who achieves transfusion independence with luspatercept but continues to have fatigue?
This is a challenging question and I'm not sure there's clear data to support a practice one way or another. Anecdotally, I have noticed that when using Luspatercept, it seems to improve hemoglobin reliably and therefore lead to less transfusions, but I have not observed a consistent concordant impr...
What genetic testing would you consider for recurrent arterial events (cryptogenic strokes, MI) in patients with limited risk factors?
This would be a case-by-case evaluation with additional history, examination and imaging features. I would take a multidisciplinary approach and also consult with hematology and cardiology. I am assuming all other workups are negative. I would probably repeat APLS labs in 6 weeks with lupus anticoa...
What is the recommended initial treatment for spinal cord compression due to non-Hodgkin lymphoma (e.g. diffuse large B-cell lymphoma)?
The answer depends greatly on clinical circumstances, such as stage of disease, degree of neurological impairment, prior treatment if any, etc. First, I would argue there is seldom a role for surgical intervention ( other then biopsy to establish diagnosis) since lymphomas are uniquely radiosensitiv...
What is your approach to treatment of infection-triggered HLH that does not respond to treatment of the underlying infection?
The algorithm our center follows is to Recognize hyperinflammation (see answer to question above -- in addition to baseline labs, we obtain an infectious disease consult) Look for and treat the trigger. A concern, if the patient is responding, is that we are missing a trigger (HLH does not occur sp...
Would you anticoagulate an SMV thrombosis caused by malignant obstruction in the setting of metastatic colorectal cancer?
Superior Mesenteric Vein Thrombosis is a rare phenomenon, within the category of Splanchnic thrombosis. While portal vein thrombosis is most often associated with cirrhosis (though also seen in many patients without cirrhosis), SMV thrombosis is more commonly seen in the context of either local prov...