Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you re-challenge a CLL patient, who had good response to Zanubrutinib but contracted cryptococcal pneumonia, with another BTK inhibitor?
Infections are part of the natural history of CLL. While cryptococcal meningitis is the uncommon one in CLL, it does occur when these patients are on steroids, have prior receipt of fludarabine, bendamustine, or other treatments which suppress the cellular immune system (in particular CD4+ T-cells)....
What parasites do you screen for in your workup of HES?
In my practice, if GI symptoms (particularly diarrhea), then culture for stool ova and parasites (broad screen). If there are no GI symptoms, then only screening for Strongyloides with a blood test for Strongyloides antibody. If there is a recent travel history or a patient immigrated from areas wi...
How would you manage a gastric MALT patient with anemia and peri-gastric and abdominal retrocaval nodal involvement?
Of course, I would first want to know if the disease was H. pylori+. Studies have shown that involved perigastric lymph nodes and deep invasion of the gastric wall are associated with a lower chance of achieving a complete response with triple therapy, but in most patients with gastric MALT (a very ...
How would you manage JAK2+ polycythemia vera during pregnancy and postpartum?
There are not a lot of data to guide us given the relative rarity of PV in adults of child-bearing age but two published studies may be helpful.An analysis of 129 pregnancies in patients with PV demonstrated that the combination of aspirin plus LMWH had a significantly lower risk of a spontaneous ab...
How would you treat ESRD patients on hemodialysis with recurrent AV fistula thrombosis found with low protein C activity?
I assume that the patient described in the vignette has a negative family and personal history of VTE. PC (and PS) deficiencies are relatively common in ESRD patients. The low levels are thoughts to reflect a combination of true (acquired) reduction and the assay interference rather than true defici...
What dose do you use to palliate multiple myeloma in a vertebral body?
For ISS Stage 1 MM patients who are going to have an OS of over 10 years, I generally prefer a more protracted regimen of 25 Gy in 10 fractions for improved durability of pain control. I typically only treat the symptomatic VB only and use inverse planning. If there is gross epidural disease or cord...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
Does plasma donation cause iron deficiency?
It really shouldn't but small amounts of blood are lost with the pheresis machine so it may occur with frequent donation. I would make sure to check from time to time. There are only marginal amounts of Fe in plasma so infrequent donations are unlike to cause iron deficiency.
How would you treat severe, symptomatic splenomegaly in a patient with ET/MF who has progressed through all approved JAK inhibitors and is not a candidate for alloSCT?
Refractory symptomatic splenomegaly to JAK inhibition is thankfully not common but does occur and requires consideration of both pharmacologic and non-pharmacologic strategies.Clinical trials should first be explored but if none are available or the patient is ineligible, then you can consider hypom...
How would you counsel a female to male transgender patient regarding VTE risk with testosterone therapy, who has additional mild-moderate risk factors for thrombosis?
If physiologic concentrations of testosterone are not exceeded and the hematocrit is monitored to avoid a pathologic level of erythrocytosis, the risk for thrombosis from testosterone GAHT does not appear to in excess of the general population. I would refer you to the following two articles that pr...