Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you approach adjusting nivo+AVD therapy for advanced Hodgkin lymphoma if a patient develops treatment limited immunotherapy toxicity?
BV-AVD-related transaminitis is relatively common; however, even with Nivo-AVD, transaminitis is frequently observed, albeit at a lower frequency. Most of these events are self-limited and grade 1-2. Depending on the stage and severity of the event, dose holds can be employed; however, adverse event...
What is your re-immunization strategy after auto SCT for patients with myeloma on dara/len maintenance?
We do the same vaccination sequence according to BMT/CTN, whether they are on maintenance dara or not. Here is our schedule Post autologous SCT vaccine Interval Date Vaccine Yearly Flu Vaccine 3-month post-transplant Pneumovax 20, Hib, hep A/hep B, polio, TDap, Shingrix 6 months post-transplant Pneu...
How would you define your radiation treatment volume for a primary diffuse large B-cell lymphoma of the L4 vertebral body that had a complete response to chemotherapy?
For a primary DLBCL involving only the L4 vertebral body with a CR after chemotherapy, we would include just the involved L4 vertebral body. There is no need to include one vertebral body above and below. Effort should be made to reduce excess dose to the bowel and adjacent bone marrow with either a...
How do you counsel an otherwise healthy patient on how soon they can go back to moderate exercise after a bilateral pulmonary embolism?
Generally, the approach is to have the patient start their exercise regimen at a lower intensity and gradually increase it based on their tolerance.
Would you use argatroban or citrate catheter lock in a patient with ESKD and HITT?
I would use 4% citrate. I have no experience using argatroban as a catheter lock solution, but have significant experience using 4% citrate solution. For our inpatients, we only use 4% citrate solution (and have done so for many years). While I believe you can buy prefilled 4% citrate syringes comme...
What is your approach to further work-up and management of neutropenia in patients with SLE/RA overlap?
This is an interesting situation that comes up in the routine evaluation of patients with rheumatoid arthritis and other autoimmune syndromes. The normocellular bone marrow suggests a peripheral destruction, in general, and raises some concerns for antibodies directed against neutrophils. These are ...
How would you treat an LGL leukemia patient who has been refractory to treatments with cyclosporine, MTX, and cyclophosphamide?
In my experience, true refractoriness to methotrexate and cyclophosphamide is unusual in LGL. What is more usual is that patients take a long time to respond and I usually don’t change therapy before a full 6 months trial of either agents. That is also what the published data suggests. In the meanwh...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
How do you approach managing depression symptoms in patients who have had repeated high risk of bleeding?
Overall, evidence suggests that while SSRIs do increase the risk of bleeding. The absolute risk of a bleeding event remains low and is usually not serious. A 2017 meta-analysis by Laporte et al., suggested that overall bleeding risk is increased by at least 36% while other meta-analyses suggest that...
How do you manage a patient with sickle cell disease during pregnancy?
I refer all pregnant women with SCD to maternofetal medicine/high risk pregnancy clinic for more frequent monitoring. I recommend a baby aspirin for preeclampsia prevention (see UK guidelines). I recommend folic acid 4 mg. If they do have iron overload, I do not recommend iron supplementation. For a...