Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Does PT/PTT elevation due to severe vitamin K deficiency protect against thrombosis?
Yes, most of us think that vitamin K deficiency increases the risk for bleeding rather than protecting against VTE.
How would you optimally manage a patient with a MDS/MPN overlap syndrome who has both transfusion-dependent anemia and marked thrombocytosis?
Patients with MDS/MPN marked by severe anemia and thrombocytosis likely have the MDS with ring sideroblast with thrombocytosis (MDS-RS-T) subtype and have a high frequency of SF3B1 and JAK2 mutations. Clinically, they resemble a fusion of MDS-RS and essential thrombocythemia (ET), both of which tend...
Is there any role for iron chelation in a patient with iatrogenic transfusion-induced iron overload such as in patients with end-stage kidney or liver disease?
There is a point with transfusion that iron overload starts to cause significant organ damage. With the advent of deferasirox (Jadenu), oral iron chelation can maintain equilibrium with ongoing transfusion. I would not start till ferritin is 1500 or higher to avoid risk of chelation of other heavy m...
When do you use clinical decision tools, like HERDOO2 or DASH, to determine duration of anticoagulation in venous thromboembolism?
I do not use the clinical decision tools as I find that they do not properly account for all variables that impact anticoagulation decision-making in a patient-by-patient case.
How do you manage a patient with no history of miscarriage but who is unable to conceive, who has a positive lupus anticoagulant without diagnosis of antiphospholipid syndrome?
I would be very leery of linking infertility to a positive lupus anticoagulant result. Whether or not the patient has antiphospholipid syndrome the evidence linking antiphospholipid antibodies to infertility (as opposed to loss of an established pregnancy) is somewhere between weak and nonexistent. ...
What is your threshold for pursuing bone marrow biopsy in a lupus patient with cytopenias?
I rarely do bone marrow biopsies in patients with SLE as cytopenias are caused primarily by the disease itself and/or medications, primarily Azathioprine and Cyclophosphamide. SLE patients routinely have profound lymphopenia, neutropenia, and thrombocytopenia. I consider bone marrow biopsy in patien...
What is the appropriate dose of radiation for a primary osseous non-Hodgkin's lymphoma?
Acceptable doses range from 30 Gy to 45 Gy. Would consider 30 Gy if there is a metabolic complete response after 2 cycles of R-CHOP and the patient got at least 4 cycles total. 45 Gy is the dose used in the prospective TROG trial of bony DLBCL, so it has some data behind it. In the femur, the bigges...
Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?
We can extrapolate from studies of venous thromboembolism associated with cancer. Apixaban (at VTE treatment dose) has been compared to dalteparin in an open-label RCT in the CARAVAGGIO trial and edoxaban was compared to dalteparin in an open-label RCT in the Hokusai VTE Cancer trial. Both painters ...
Do you typically recommend four factor prothrombin complex concentrate versus fresh frozen plasma for INR correction in patients with vitamin K antagonist associated spontaneous ICH?
Great question! Despite the lack of large randomized controlled trials, PCCs achieve faster reversal of the INR level than FFPs do, and thus I favor using PCCs with Vitamin K as a first line agent for Vitamin K antagonist related ICH.
What frontline therapy would you offer for a patient who is elderly or unfit for standard induction therapy with both IDH-2 and FLT-3 ITD mutations?
For a newly diagnosed patient, unfit for induction chemotherapy with both an IDH2 and FLT3 mutation, I would offer HMA with venetoclax for the initial treatment. While both the IDH2 inhibitor Enasidenib and the FLT3 inhibitor Gilteritinib are both well-tolerated drugs with good remission rates, if y...