Benign Hematology   

For ESRD patients with decreased Protein C activity level, the purported etiology may be a dialyzable substance in uremic plasma that interferes with ...

For example, in a patient with ongoing GI bleeding already on monthly IV iron dextran 1000 mg, would you consider dosing more frequently at Q2 or Q3 w...

Is treatment indefinite or do you consider discontinuing chronic transfusions at some threshold?

New data suggests monoclonal gammopathies can be associated with thrombotic events. Is your practice changing to include monoclonal gammopathy evaluat...

For example, would you consider this method in an ESRD/HD patient with antiphospholipid syndrome who had a major bleed requiring reversal of warfarin ...

Labs with normal PT, but prolonged PTT (47 sec, ULN 40 sec) that does not correct on immediate mix. Lupus anticoagulant negative (DRVVT and hexagonal ...

How often does this occur and does this lower your suspicion for a "true" or clinically significant lupus anticoagulant?

Presuming good medication adherence.

Assume the patient does not have another indication for AC like VTE or AFib. Could this be suggestive of a hypercoagulable state?

vWF and FVIII activities ~200% and were checked because of the patient's family history of "coagulopathy". Is there any utility in repeating the test...

How would you approach anticoagulation in this situation? Does the presence of thrombocytopenia or hemorrhagic splenic infarcts change your manag...

For what duration and is there a preferred anticoagulation agent?

Do you consider starting Ursodiol? Do you perform routine abdominal ultrasound to monitor for cholelithiasis?

UpToDate recommends Hydroxychloroquine for all SLE patients, but neutropenia is sometimes ascribed to HCQ rather than the underlying disease. What lev...

Do the presence of gastric varices and use of anticoagulation change the way you think about using these agents?

Would you consider chronic RBC exchange versus HU?

Are there specific guidelines for managing this patient population?

What is your preferred anticoagulation in patients with BMI >50?

For B12 levels >2000-4000.

Do social or economic factors (i.e., relative cost of acquiring LMWH, the patient being injection averse) affect your decision to use DOACs? Do you s...

Does this hold true when the patient has significant inflammation? 

HFE gene mutations in C282Y and H63D are negative.

Is a BM biopsy a must when there is skin involvement? If tryptase level is mildly elevated but less than 20 would you recommend a BM biopsy?

Aside from addressing the underlying case, is there a role for phlebotomy in secondary polycythemia such as in COPD or post-renal transplant erythrocy...

In the setting of requiring anticoagulation for atrial fibrillation and bioprosthetic valve, but also having severe vitamin K deficiency, would you st...

Ferritin >2200, TSAT >80%

There are various formulations of intravenous iron; each with varying costs, test dose requirement, elemental dose, and number or time of infusions ne...

Common thought is that FVIII may be used for differentiating coagulopathy in liver disease (normal to increased, from reduced clearance of VWF/FVIII) ...

I.e. platelet count <30. Would your management change if HIT were only suspected rather than confirmed?  

Level >60%. No family or surgical h/o of bleeding but heavy postpartum bleeding.

Hb <11, low iron saturation (<10%), high ferritin (>900), and low reticulocyte hemoglobin equivalent.

Is it only done when heparin is used in an emergency?

If so, for how long? 

What is the work up and what is the duration of anticoagulation if used?

E.g. Normal F8, VWF activity ~50%, VWF antigen ~100%, ratio 0.5 sent in a patient with positive bleeding history Is there any clinical significance t...

Specifically, asymptomatic subsegmental PE diagnosed within a month from planned bilateral mastectomy for breast cancer. 

Significant history of autoimmune diseases and DVT in family, recent PE/DVT for a month

Nonreliable INR, given hepatic coagulopathy

Although TIBC is negative acute phase reactant, would it be a better indicator of iron deficiency (in combination with ferritin)?

Also how would you manage this perioperatively?

Often see bariatric surgery ordering these tests, is there any clinical relevance?

Would it change your management if the thrombus was symptomatic? Or if larger >3 cm?

For example, a patient with a bone marrow biopsy that shows normocellular bone marrow. Prior management with leflunomide and HCQ with neutropenia attr...

Any particular labs or imaging indicated?

What can you recommend that might help keep them out of the hospital? Do you consider a program of exchange transfusions in this situation?

If so, what platelet count threshold would you use? Would age impact your decision? Would you do a bone marrow to rule out primary MPD in adults if th...

In the absence of concerning bleeding or thrombosis, family history of coagulopathy, current anticoagulant use, or malnutrition

Is SLE-related APLS managed differently in terms of anticoagulation?

Ferritin uptrending >1000, no additional lab abnormalities. HFE wildtype. Too young for age-appropriate cancer screening. Asymptomatic except fatig...

Is thrombotic risk too significant? Patient failed OCPs.

(Normal oxygenation and echo)

If so, is there one type of antibody that is more likely to cause this false positive test? 

For example, if TSAT is less than 20% but ferritin is over 200. 

For instance, evaluation by primary care and GI without other etiology for splenomegaly

Do you just use antibiotic prophylaxis if therapy is started prior to meningococcal vaccination?

ALC<200

- Dialysis catheter used for hemodialysis- RIJ thrombus in dialysis catheter was incidentally found- Patient asymptomatic with no prior history of VTE...

CRP 39 mg/L (normal < 10) and normal ESR

APLA syndrome, obesity, non compliance ruled out and prefers another oral anticoagulation. Is higher dose of rivaroxaban or apixaban an option?

Bleeding disorder such as vWD

Presuming strong indication for ASA - eg history of NSTEMI

Should we stop checking factor VIII levels as part of thrombosis workup?

In the setting of no personal or family history and no other risk factors for thrombosis, is systemic anticoagulation warranted if local treatments (e...

(e.g. beta 2 glycoprotein IgM > 20 but <40)

e.g. K, Fya, s, etc

In the absence of a VTE would you consider prophylaxis after a surgical procedure? Often non-hematologists order this testing but we are consulted for...

IVIG, TPO, or other agents?

Please comment on bridging.

What should be done with a high level?

For example, for outpatients or resource-limited settings with a moderate probability 4-T score (but low clinical suspicion), would you ever consider ...

e.g. in the setting of using prophylactic heparin in the past but now requiring therapeutic anticoagulation

Please also discuss the type and duration of anticoagulation.

Is there a particular sequence you would adjust contributing antirejection or antimicrobial medications? Is the use of G-CSF appropriate and at what c...

Have you used anticoagulants other than coumadin? Or is that the only appropriate agent given monitoring is based on PT/INR?

What if the patient is no longer responding to steroids?

Does transplant eligibility make a difference for management?

Is there any difference between anticoagulants in this clinical context (e.g. anti-Xa inhibitors vs warfarin vs LMWH)?

Is there a role for empiric antibiotics if there is history of opportunistic infection?

When do you consider initiating eculizumab?

For a patient with low ferritin, but high TSAT?

For example, in cold agglutinin disease or AIHA, antibodies can be detected via DAT, but are often not observed on assays for monoclonal gammopathies.

Such as a patient who cannot tolerate oral iron and has had a anaphylaxis to intravenous iron

For example, a patient with hypogonadism unless it matters which organ is involved. Are other markers of iron storage useful in guiding therapy?

If autoimmune neutropenia already suspected, is this test informative or unnecessary?

What is the lowest level you have seen with uncomplicated or complicated crises?

Do you go straight to TMPRSS2 genetic testing or what other lab testing (e.g. hepcidin) could be helpful?

Is there a preferred strategy of transfusional support versus reduced-dose anticoagulation during the duration of thrombocytopenia?

What if this was "triple-negative" antiphospholipid syndrome?

Does recent iron intake affect the iron panel, and if so, do you often order fasting labs in practice?

Does your opinion change based on the specific underlying inherited thrombophilia? The original case was a central retinal artery occlusion in a patie...

Especially in a patient without hemophilia or thrombosis history?