Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you offer rituximab maintenance for 2 years after a successful response to induction in a patient with splenic marginal zone lymphoma?
The answer will depend on age, performance status of the patient, thrombocytopenia, etc. No difference in OS was noted but freedom from progression was noted in rituximab group. 1 year did as good as 2 years maintenance.Kalpadakis et al., PMID 29914978
Would you offer treatment for asymptomatic CLL with WBC of ~300k or greater, high risk cytogenetics, or doubling time of 6-12 months?
Generally, starting treatment in a CLL patient is recommended based on the iwCLL criteria (Hallek et al., PMID 29540348).There is no WBC threshold that would require to treat, but the vast majority of patients with a WBC of 300K will have other reasons to start therapy. If this would be a patient wi...
Are there any reasons to consider a prolonged course of steroids with taper over a shorter course of pulsed steroids in the treatment of ITP?
As a general rule in pediatric ITP, I would say the answer is "no" but there are some exceptions. I'll defer to adult hematology colleagues to address this question for older patients, but some basic principles apply. 1. Steroid doses after an initial pulse, should be as low as possible because of ...
What is your approach to VTE prophylaxis following hematopoietic stem cell transplant?
My general approach is to offer VTE prophylaxis for patients with acceptable platelets count/absence of coagulopathy upon admission to the BMT unit for transplant and to continue until platelets are < 50k. I do not offer routinely VTE prophylaxis after SCT at discharge from the BMTU unit, with the e...
How do you approach diagnosing a patient with Iron Refractory Iron Deficiency Anemia (IRIDA)?
Iron-Refractory Iron Deficiency Anemia should be suspected when there is a lack of response to oral iron and only a partial response to intravenous iron. One should make sure there is not a chronic underlying inflammatory process to explain the lack of iron absorption or lack of the expected respons...
Do hemoglobin S levels always correlate with SCD phenotype?
The severity of sickle cell disease (SCD) is usually associated with the level of hemoglobin S (HbS). For example, HbSS and HbSB0 thalassemia, which generally have higher HbS levels, are usually more severe than HbSC and HbSB+ thalassemia. While patients with HbSC and HbSB+ thalassemia typically hav...
Is there a role for anti-neutrophil antibody testing in the workup of neutropenia?
In my view, anti-neutrophil antibodies add little to the work-up of neutropenia. Drs. @Dr. First Last and @Dr. First Last presented an abstract at ASH in 2015 that summarized restyles for 60 pediatric persons with a diagnosis of autoimmune or idiopathic neutropenia. The sensitivity and specificity o...
Would you place an IVC filter in a patient with an acute PE and an absolute contraindication for anticoagulation, but negative imaging for proximal DVT?
Good question. In this scenario, it would be reasonable to place an IVC filter. I would also image the IVC/pelvic veins in an effort to locate the origin of the embolus. A residual clot (depending on the size) may affect the approach to placement of IVC filter. Other variables include whether the PE...
How would you manage OCPs in a patient who develops a VTE while on treatment?
If a patient has a venous thromboembolic event, while on a combined estrogen-progesterone oral contraceptive, it is reasonable to continue the OCP with the initiation of anticoagulation. A study from 2016 revealed that it was safe to continue hormone therapy with the anticoagulation (Martinelli et a...
What are your thoughts on adding mycophenolate to steroids in the first line treatment of ITP based on the results of the FLIGHT trial?
This was an impressive study that should alter how upfront ITP is managed. The study was well designed, with randomization against the current standard of care. Efficacy was clear with HR for treatment failure of 0.37 (p=0.0029). What is also nice is that unlike TPO agonists which do not have define...