Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you manage distal DVT in first trimester of pregnancy?
This is an excellent question. Essentially, this is an individual with an acute, provoked distal DVT in the setting of pregnancy. ASH 2018 guidelines for management of VTE in pregnancy recommends antithrombotic therapy with LMWH for individuals with acute VTE (Bates et al., PMID 30482767). While the...
What antibiotic, antifungal and antiviral prophylaxis you give post CAR-T therapy, and what is the duration?
This is a critical issue as more patients are being treated with CAR-T cell therapy. My approach would be as follows: Antiviral PPx: I usually consider acyclovir PPx for at least 1 year Antifungal PPx: Consider fluconazole PPx for initial neutropenia if it is prolonged beyond a week ---> once the c...
For von Willebrand type 2B, do you expect a decline in platelet count over time as vWF increases with age?
Von Willebrand factor levels increase with age in normal people and in those with type 1 VWD. There is no or a much lesser degree of VWF rise in variants type 2 and 3. I would not expect a significant decrease in the platelet count in a patient with type 2B with increasing age, but if it occurred, ...
At what ferritin threshold would a patient with anemia of inflammation or malignancy no longer benefit from iron supplementation for functional iron deficiency?
There is no level. I have given IV iron to people with low TSATs and ferritins in the thousands. 200 isn't even close to too high.
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...