Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Do you routinely evaluate patients with collagen disorders or Ehlers-Danlos for platelet defects?
Yes, I routinely carry out a full hemostasis evaluation, including platelet aggregation and release studies, in patients referred to me with easy bruising and hypermobility with an increased Beighton score suggesting EDS and in those already diagnosed genetically with EDS. EDS patients typically hav...
What are the best labs to trend improvement in HLH?
Unfortunately, there is not one specific laboratory test to definitively trend responses to HLH directed therapy. In general, our approach is to obtain baseline inflammatory labs including CBC with differential, ferritin, soluble IL2 receptor (sIL2r), triglycerides, coagulation studies (PT/PTT) incl...
Would you offer live vaccines (e.g., MMRV/measles) to patients on bispecific antibodies for multiple myeloma?
I agree with the answer here by Dr. @Dr. First Last. There are a lot of nuances, though. In regard to giving the vaccine safely and effectively, the best strategy is not to wait until patients have multiple relapses and are on bispecific therapy to vaccinate. Given the recent outbreaks of measles, i...
How do you approach initial anticoagulant selection in hemodynamically stable hospitalized patients with newly diagnosed pulmonary embolism?
Low-molecular-weight heparin demonstrates the greatest benefit in patients with cancer-associated pulmonary embolism, intermediate-risk PE, and those requiring outpatient management. While LMWH shows superior efficacy and safety compared to unfractionated heparin across most patient populations, cer...
For transplant-ineligible aplastic anemia planned for immunosuppression, how do you approach duration and tapering of cyclosporine and eltrombopag?
One of the most common mistakes in the management of AA is premature tapering of cyclosporine or tacrolimus. If there is a complete remission, and by that I mean normalization of counts, not complete remission as defined in some papers (e.g., ANC 1000, Plts 100,000, Hb 10 as in de Latour et al., PMI...
What is your preferred assay for assessing dabigatran levels?
The only specific assay that would reflect drug levels is the ecarin clotting time with dabigatran as a calibrator. We used to have this assay in our lab, but due to a lack of use, it was discontinued. The standard thrombin time is too sensitive; however, dilute thrombin time has been used. The mass...
Would you supplement iron for low iron studies in absence of anemia?
The answer is absolutely and positively. Iron deficiency causes symptoms independent of anemia which include fatigue, brain fog, restless legs syndrome, and pagophagia and other forms of pica. You simply cannot dignify waiting for overt iron deficiency to develop in someone with symptomatic iron def...
What guides your choice between prophylactic, intermediate, and full therapeutic dosing of enoxaparin in a woman with APLS and prior fetal loss with no hx of thromboembolic disease?
First, it is essential to confirm that patients meet criteria for obstetric antiphospholipid antibody syndrome (OAPS), based on the 2023 ACR/EULAR classification criteria. This includes persistently positive laboratory criteria (confirmed on repeat testing >12 weeks apart), plus otherwise unexplaine...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
Would you expect a reduced neutrophil count in individuals with a partial duffy null phenotype?
The Duffy null phenotype's impact on neutrophil counts is "all or none". Approximately one-third of patients with the Duffy null phenotype Fy (a-b-) will have a neutrophil count below the usual lower limit of normal. The range of neutrophil counts in individuals with Fy (a+b-) and Fy (a-b+) is exact...