Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you treat factor XI deficient patients with surgery or trauma related bleeding?
Given the risk of elevated plasminogen with low FXI, prefer FFP, with fibrinolytic if mucosal bleeding.
When would you initiate chronic therapeutic phlebotomy in a patient with erythrocytosis secondary to a high hemoglobin-oxygen affinity hemoglobinopathy?
The large majority of patients with high oxygen affinity hemoglobinopathy do not require therapeutic phlebotomy. There is a subset of patients who develop symptoms (generally these are non-specific such as headache) or complications such as thrombosis. There seems to be no correlation between hemato...
Do you recommend lifelong antibiotic prophylaxis, or do you prefer a more selective approach based on risk factors in asplenic patients without a history of severe infections?
The advice is limited by the fact that there are no randomized controlled trials in adults on daily antibiotic prophylaxis post-splenectomy. There are trials in children with sickle-cell disease that do show a benefit, but it is not clear that these can be extrapolated to splenectomized adults. Furt...
Would you consider elective neck nodal irradiation for a large >5 cm head and neck extramedullary solitary plasmacytoma arising from the nasal cavity?
A plasmocytoma in the nasal cavity may bear a higher risk for nodal involvement if it involves Waldeyer's ring or nasopharynx.Adding ENI to the neck will certainly increase the risk of toxicity and only lead to a modest benefit in terms of isolated regional recurrence. I would thus not perform elect...
Should post-transplant cyclophosphamide be utilized for all matched unrelated donor peripheral blood stem cell transplants for hematologic malignancy?
In myeloablative transplantation, PTCY did not have an advantage over Tac/MTX as demonstrated in the BMT-CTN 1301 study which compared PTCY, Tac/MTX, and T cell depletion (Luznik et al., PMID 34855460). One caveat is that in this trial, PTCY based prophylaxis did not include Tac or Tac/MMF.BMT-CTN 1...
In a patient with cryptogenic stroke while on antecedent aspirin 81 mg, how do you decide between single antiplatelet therapy, dual antiplatelet therapy, or antiplatelet agent combined with anticoagulation such as rivaroxaban 2.5 mg BID?
This question assumes that a thorough workup has been completed, and the patient does not have paroxysmal a fib, a PFO, an intracranial stenosis, a hypercoagulable state, or vasculitis. This workup is the most important issue. If all is negative, and the stroke is relatively minor (NIHSS less than o...
What are alternative myeloma therapies for patients who are unable to afford lenalidomide or oral cyclophosphamide due to gaps in prescription drug coverage?
Unfortunately, this is a big problem, especially in community centers where the resources for grant applications are scarce. At bigger institutions, like ours, we have a dedicated person who searches for all possible grants. If unable to, then the pharma companies have been generous to give free dru...
For patients with essential thrombocythemia already on prophylactic dose DOACs, do you defer starting aspirin?
I usually defer aspirin in these situations. There is evidence from PV that aspirin plus anticoagulation increases bleeding risk (Zwicker et al., PMID 34162181). If an ET patient has a high-risk disease with prior arterial thrombosis, then I would favor adding aspirin.
Does evidence support extending the duration of intravenous iron dextran (INFeD) infusion in pregnant patients?
No, there has never been evidence with any of the four formulations supporting a longer rate of infusion (above the minimum recommended) as a harbinger of either benefit or safety. LMW ID (INFeD) should be given as 1000 mg in 250 ml of normal saline over one hour. My gut tells me 45 minutes is OK bu...
How do you counsel patients with acute intermittent porphyria when it comes to fasting for religious reasons?
This is a very difficult question and it depends on the individual patient, their disease severity, their particular triggers, and how they have done in the past with caloric restriction. The patient may want to speak with a clergy member for guidance in this situation as well. For inst...