Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What would you use for cytoreduction in a pregnant patient with high risk ET and APLS?
My first instinct in replying to this question is to understand the basis for the diagnosis of “high-risk ET”. Since the patient is pregnant, the basis for the designation “high-risk” must be a history of a prior thrombotic event, either arterial or venous. However, the purveyors of the various MPN ...
Would you change therapy for a CML patient in hematologic remission on imatinib found with positive qualitative BCR-ABL1 for the p230 protein?
It would depend on how long the patient has been on imatinib and the sensitivity of PCR testing. Being able to monitor the p230 transcript at the level of 0.1% or even deeper would be helpful to characterize if the patient has achieved a major molecular response or not. This publication outlines the...
What is your approach for bulky stage I primary mediastinal B-cell lymphoma in a patient with a positive post-chemotherapy PET-CT (residual mass and Deauville 5)?
Interpreting end-of-treatment PET in PMBL can be tricky. False positives here are very common! Fake-outs include thymic rebound masquerading as refractory disease; avidity at rim (which is almost always biopsy-neg); or residual avidity throughout residual mass which again can be biopsy negative. I w...
Does aspirin dose (81 mg vs 325 mg) matter for secondary stroke prevention?
This topic has been debated extensively. There are two camps in this debate: Aspirin with a dose of 81 mg is adequate for platelet inhibition in the general population. Aspirin with a dose of 325 mg may be needed for individuals who weigh more (>70 kg) to achieve appropriate platelet inhibition. T...
Are you including Bortezomib as standard of care in the upfront treatment of T lymphoblastic-lymphoma?
We do use bortezomib in the upfront treatment of T-cell lymphoblastic lymphoma in children and AYA. For those familiar with the topic, the results of two successive large clinical trials in T-LLy done by COG, AALL0434, and AALL1231, were confusing. Due to the rarity of the disease, overlapping trial...
Is there any indication for hydroxyurea in patients with sickle cell trait?
No. Of course, be sure it is the correct diagnosis and not HgA + HgS (beta+) which, as you know, shows HgA and HgS on electrophoresis and can/will be called trait if not looked at by someone experienced to note if A> S or if S > A. If MCV is low. If HgA2 is up. HgF up etc... If indirect Bili/LDH/AST...
Would you start anticoagulation in a patient with provoked blood clot in the past now with labs done for rheumatological reasons showing triple positive APLA?
The short answer is that I would probably not anticoagulate this patient as a history of prior thrombosis is hard to connect to the currently positive APL antibodies. I would certainly obtain a second set for future risk stratification. However, there are several variables that could influence the ...
How do you manage arthritis resulting from deferiprone in transfusion dependent thalassemia?
The precise pathophysiology of deferiprone associated arthropathy is not well understood but some reports have suggested that there may be some deposition of iron in the synovial membranes, and some subchondral bone damage. Unfortunately, there is no specific treatment for this arthritis, other than...
What workup do you perform for elevated B12 levels in an adult who is not taking supplements?
There is no convincing evidence of the harmful effects of elevated serum B12 per se, so I have not vigorously pursued this lab finding. If excessive supplements are consumed, B12 is innocuously excreted in the urine once tissue receptors are saturated. Nonetheless, this question raises some interest...
How do you manage mild Type 1 von Willebrand disease undergoing wisdom teeth removal?
This depends on the patient's past personal and family bleeding history with past challenges and on the VWF levels. If past challenges are known and no bleeding has occurred, and if the VWF levels are 30 IU/dL or greater, I would give only EACA p.o. pre and post. Intranasal DDAVP 2 hours prior and 4...