Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Do you find IgA isotypes of anti-beta2-glycoprotein antibodies and anticardiolipin antibodies to be clinically useful in the evaluation for APS?
I would answer yes to this question. We believe an isolated IgA elevation of AcL or anti-B2GPI carries diagnostic relevance in the right clinical context. We routinely look for all Ig isotypes in our diagnostic evaluation of APS. In fact, our group published the first such article.Murthy et al., PMI...
Would you consider using HMA in management of polycythemia vera?
The short answer is no. However, it depends on what is going on with the patient and what is meant by refractory? If one is managing symptomatic PV or trying to control counts then hydroxyurea, pegylated interferons, and ruxolitinib are the available options and it is worth mentioning that ropeginte...
How long do you give systemic therapies or skin directed therapies to work before changing treatments in patients with diffuse skin limited mycoses fungoides?
It really depends on the patient, the side effects profile. Some systemic therapies are “skin directed” like bexarotene. Also, access to a dermatologist's office for nbUVB is an important factor in making such a decision. I generally don’t recommend topical agents when there is more than 10% eBSA sk...
What is the role of splenectomy versus systemic therapy in splenic marginal zone lymphoma?
With the introduction of rituximab and other CD20 monoclonals, the role of splenectomy in splenic marginal zone lymphoma is shrinking. There are rare clinical scenarios where I would still recommend splenectomy in splenic marginal zone lymphoma; huge splenomegaly with disabling symptoms, splenic tra...
When would you consider an umbilical cord blood transplant over a haploidentical transplant with post-transplant cyclophosphamide, or using a desensitization protocol for high donor-specific antibodies?
High DSA are a real problem. We generally use an MFI of 1000 as a threshold - below that there is less concern. Confusingly, even with high DSA, the rejection rate is not 100% so it is often tough to make a decision. UCB transplantation is somewhat inferior to haplotransplant in terms of overall out...
Should a pregnant woman who is heterozygous for factor V Leiden who has never had a thrombotic event receive prophylactic anticoagulation?
This is a common situation and lacks evidence based recommendations. Recent ASH guidelines (Bates et al., PMID 30482767) suggest against routine antepartum prophylaxis in this situation. However, it is important to have a balanced discussion with the patient. In my experience, most would choose prop...
How do you approach heparin management in patients who have suprathetherapeutic Xa levels on minimal heparin?
Assuming heparin is administered using standard weight-based dosing, that the infusion rate is being accurately monitored, and that the assay was done properly, very high anti-Xa levels that persist despite lowering the heparin dose would be most unusual. In that setting, I would suspect that either...
How do you manage recurrent portal vein thromboses in a patient with JAK2+ PV on therapeutic anticoagulation and appropriate cytoreduction?
How do you manage recurrent portal vein thromboses in a patient with JAK2+ PV on therapeutic anticoagulation and appropriate cytoreduction? Recurrent thromboses despite therapeutic enoxaparin. Other hypercoagulable work-up negative. This clinical situation is one of the three pressing unresolved pro...
Does potential longterm risk for leukemia influence your decision for using hydroxyurea in young patients with myeloproliferative neoplasms?
Thanks for the great question. I think there is a range of passionate options about the matter, which is sure to stir up debate. One can infer by the number of opinions on the topic, the data is limited (where data lacks, opinions abound). So here is my take: It does not influence my decision making...
How do you manage real-time release of pathology and radiology results to oncology patients following enaction of the CURES act?
Even prior to the Cures Act, I worked in a place where lab and imaging results were immediately available to patients through their smartphone app. A few memorable encounters: Patient 1 - told me his favorable PSA result when I walked in the room and basically told me the plan going forward, (which ...