Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What radiation dose would you use to treat a symptomatic osseous lesion secondary to AL-amyloidosis?
Extrapolating from our tracheobronchial experience, we’ve used 20 Gy in 10 fractions to target the underlying plasma cells that produce amyloid production. We’ve also used this regimen for ocular and GU (ureteric and bladder) amyloidosis. If there are obstructive or symptomatic lesions, then surgica...
What is the role of anticoagulation in patients with septic thrombophlebitis?
The role of heparin anticoagulation in septic thrombophlebitis is controversial. There are limited to no randomized trials to document outcomes. A systematic review (Falagas et al., PMID 17222406) supported this practice, and the Infectious Disease Society also supports this practice. The role of or...
How do you interpret elevations in ESR and CRP in the setting of increased BMI?
Increases in BMI (overweight and obesity range) have been shown to be associated with elevated CRP and ESR, with stronger associations shown with CRP specifically. Interestingly, the association between elevated CRP and obesity seems to be stronger in female populations than in male patients.In the ...
How should one monitor for and manage CMV reactivation in patients receiving alemtuzumab?
Here's how I approach it: Baseline Testing: Perform CMV serology (IgG/IgM) and quantitative CMV DNA PCR before initiating alemtuzumab to establish baseline status. Frequency: Weekly PCR testing for 8–12 weeks post-infusion, focusing on the high-risk window (weeks 3–6). Extend monitoring ...
Are there specific findings that would make you suspicious of IgD or IgE monoclonal gammopathies?
I mostly consider an IgD or IgE monoclonal gammopathy in a patient who has a measurable serum M-spike on serum protein electrophoresis but a serum immunofixation that only shows a light chain band (either kappa or lambda). Since patients with light chain-only myeloma usually have at most a tiny mono...
How long would you anticoagulate for PE developed after air travel in a woman on an estrogen-containing vaginal ring for contraception?
This patient has two transient (“provoking”) factors that may have contributed to her pulmonary embolism (PE): the use of estrogen-containing contraception and, presumably, a recent long-haul air travel. Traditionally, it has been assumed that, after three months of treatment for the initial venous ...
Are there instances where you can defer on mass spectrometry testing for amyloid typing in Congo Red positive tissue?
This is a great question and one that is not uniform in its answer depending on the clinical situation.Assuming we are talking about at diagnosis here, the short answer is always send Congo red positive bone marrow findings for mass spec typing if there is enough positive protein to dissect and type...
How do you follow pulmonary embolism patients who have completed anticoagulation?
3 months after sustaining an acute PE, I asked the patients if they were back to their pre-PE level of functional capacity. If they are not, i.e. if they remain dyspneic, I get an echocardiogram and a VQ scan. If the echo during the acute PE shows RV strain or evidence of pulmonary hypertension, I r...
Regarding CVST, what protocol of heparin dosing do you regularly use and does it change depending on clot burden/ICH status?
There is very limited randomized evidence for the use of anticoagulation in any form for CVST. We often rely on extrapolations from data on the acute management of DVT in the leg and pulmonary embolus. We are mainly limited to cohort studies and small RCTs. Recent trials in this area include the TO-...
Would you consider long term avatrombopag use in patients with cirrhosis requiring higher platelet counts for medical therapy?
In general, no, I would not use long-term avatrombopag in patients with cirrhosis requiring higher platelet counts for medical therapy due to the perceived thrombotic risk and hemostatic abnormalities of patients with liver disease.One thing to note in assessing the risk of long-term TPO mimetic the...