Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do CLL patients with downstream treatment-resistant mutations such as PLCG2 respond to pirtobrutinib?
Although BTK/PLCG2 mutations are present in patients with CLL relapsing on covalent BTK inhibitors, more than one-third of them DO NOT harbor such mutations even after high-sensitivity analyses. Additional genetic mechanisms, in particular aberrant activation of the BcR and NF-κB pathways, may be re...
Does tolerance of prior BTKi therapy or specific agent used (e.g., ibrutinib, acalabrutinib) influence your starting dose of pirtobrutinib?
Not really. I generally start pirtobrutinib at the standard dose of 200 mg daily.
Would you consider IV thrombolytics in patients with acute ischemic stroke, with or without a large vessel occlusion, if they have a history of von Willebrand disease (VWD), regardless of its type?
I would still consider it unless the INR >1.7 or they are on anticoagulation for some clinical reason.
How do you treat patients with T-cell ALL/T-cell lymphoblastic lymphoma who have pre-existing CKD with a CrCl of 30 mL/min or less?
In our experience, it requires very close coordination with our clinical pharmacists to ensure proper dose adjustments are made. By doing this, you will hopefully deliver comparable dose intensity without increased toxicity. This assumes you achieve the same level of drug exposure for the agents tha...
Can a patient still have primary HLH even in the absence of any HLH associated genetic mutations?
Yes, a patient can still have primary Hemophagocytic Lymphohistiocytosis (HLH) even in the absence of identified HLH-associated genetic mutations.Primary HLH, also known as familial HLH, is typically linked to mutations in genes related to the immune system, such as PRF1, UNC13D, STX11, STXBP2, and ...
When considering the use of DOACs in APLS, does the number of positive APLS antibodies influence your decision?
The number of antibodies is an important consideration.On the one end of the spectrum, I would not recommend any DOACs in a triple positive APLS (especially with arterial thrombosis). Having said that, I would not change treatment in a triple positive APLS patient if they were started on DOACs in th...
Do you always initiate hypercoagulable work up in a patient with recurrent stroke?
As always, this is a more complex problem than it appears. A history of both prior other thrombosis and family history of thrombosis is essential. Are there good reasons for the stroke and/or has it been worked out in past including carotid disease, atrial fibrillation, underlying malignancy, valvul...
How will you treat a young man with recurrent cryptogenic strokes with no identifiable cause, with MTHFR A1298C homozygous mutation and normal homocysteine level?
The genetic variant you report seems to be a SNP that, while it has been reported to be statistically associated with various diseases in GWAS studies, is not pathogenic. SNPs that are significant in GWAS studies have very small effect sizes that can be measured when considered in thousands of peopl...
Can lupus anticoagulant be positive despite a normal aPTT?
aPTT is one of the assays that may be abnormal in the presence of lupus anticoagulant, but not always. Usually, when screening for lupus anticoagulant, there will be a "special" aPTT assay used that is a bit more sensitive to detect lupus anticoagulant. There are several different aPTT-based assays ...
How do you modify the hemoglobin goal and ESA dosing for patients with sickle cell anemia and ESKD on hemodialysis?
In sickle cell patients, I coordinate care with the patient's hematologist. I will reduce the hemoglobin goal to 8-10 g/dl, and if patients have a history of crises, closer to 10 g/dl, I may choose 7-9 g/dl. ESA requirements seem to be higher in sickle cell patients, so I would start with 100 units/...