Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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...
How do you counsel patients on the risk of thromboembolic complications with use of immunotherapy in NSCLC?
Patients with metastatic lung cancer are at increased risk of thromboembolic events with an estimated frequency of 13.9% (Connolly et al., PMID 23026639). Preclinical data show that PD-1/PD-1 pathway blockade may lead to increased levels of pro-inflammatory cytokines and T cell driven progression an...
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...
How would you determine the safety of anticoagulation in patients with evidence of cerebral microhemorrhages who present with acute stroke secondary to cardioembolism?
This question assumes that the patient already had an MRI showing microhemorrhages. The Boston criteria provide guidelines for the number of microbleeds, associated superficial siderosis, or major hemorrhage to make the diagnosis of cerebral amyloid angiopathy. I would also assume that at least some...
What is your preferred treatment agent for type 1 von Willebrand patients needing minor procedures if they have a history of severe hyponatremia with DDAVP?
I would avoid DDAVP. I typically individualize hemostatic management based on the procedure- related risk of bleeding and severity of the VWD. For example, for dental extraction, tranexamic acid alone may suffice; however, communication with the proceduralist to use topical agents such as topical th...
In patients with inflammatory arthritis (RA, psoriatic arthritis) and a history of MGUS are there any concerns regarding use of biologics?
There is no absolute contraindication to any particular biologic used to manage active RA in a patient with MGUS. The literature does point out a small potential risk associated with tocilizumab in terms of development of myeloma influenced by the IL-6 pathway (and I would tend to extend that potent...
In what clinical scenario would you consider liver transplant evaluation for a patient with sickle cell hepatopathy?
I would do a concurrent stem cell transplant - in an effort to cure the underlying problem of sickle cell disease. Ideally, the same donor to prevent graft rejection.
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
How do you decide whether to hold acalabrutinib or zanubrutinib in patients with indolent B-cell lymphoma/leukemias in a perioperative/periprocedural setting?
This is always a point of discomfort among providers, but it can actually be made quite easy. BTK inhibitors have known antiplatelet effects similar to low-dose aspirin. Consequently, if the surgeon holds aspirin for the planned procedure, I generally recommend that we hold the BTK inhibitor for 3 d...
Do you check IGHV mutation status in patients with newly diagnosed CLL?
Yes. In the targeted therapy era, there are three factors that continue to have prognostic and therapeutic significance and should be checked: IgHV mutation status p53 aberrancy - requires both FISH for del17p AND mutation analysis for p53 Complex karyotype - can be done on peripheral blood or marr...