Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What would be your transfusion strategy for a patient with decompensated cirrhosis presenting with concomitant acute upper GI bleed and acute MI?
I would be guided by the patient's vital signs, response to crystalloids, and clinical findings for red cell transfusion decisions, more so than any hemoglobin/hematocrit determination. I would avoid plasma transfusion for INR/prothrombin time abnormalities unless the viscoelastic testing demonstrat...
What genetic testing would you consider for recurrent arterial events (cryptogenic strokes, MI) in patients with limited risk factors?
This would be a case-by-case evaluation with additional history, examination and imaging features. I would take a multidisciplinary approach and also consult with hematology and cardiology. I am assuming all other workups are negative. I would probably repeat APLS labs in 6 weeks with lupus anticoa...
Do you perform a bone marrow biopsy in all patients with grade 5 anaphylaxis to stinging insects and negative workup for HAT, MCAS, c-KIT?
Before saying that bone marrow biopsy is the next step (which it is), we must be certain that we are correctly assessing the situation. Was there documented hypotensive shock (and not just subjective light-headedness or brief vasovagal syncope? Were there other objective signs like urticaria (althou...
What is your approach to post-kidney transplant erythrocytosis for an asymptomatic patient already on ACEi but with Hb consistently >18?
My approach is to rule out non-transplant-associated causes of erythrocytosis (examples include obstructive sleep apnea, checking for renal artery stenosis, etc.). Once the diagnosis of post-kidney transplant erythrocytosis has been met, we typically use ACEi/ARB as you mention in the question. If t...
Would you consider octreotide as an adjunctive therapy for patients experiencing an acute life-threatening hemorrhage, outside of standard indications such as variceal or AVM bleeding?
In very selective scenarios, when the patient is experiencing an acute life-threatening bleeding while variceal or AVM bleeding remains on the differential, yes, I would consider octreotide as an adjunctive therapy, but only as a bridge to definitive diagnosis and treatment and not as a substitute f...
For atrial fibrillation patients with high risk of CVA who cannot tolerate full dose AC due to bleeding, do you consider low dose/extended dosing anticoagulation even if they do not meet age/GFR criteria for a dose reduction, if Watchman is not readily available as an option?
Most drugs, including anticoagulants, have a dose-response. Therefore, one could argue that even though DOACs were not studied at low doses, except in defined sub-groups such as the very elderly, using such a dose in other situations may have some benefit. The problem is that without data, we simply...
Would you consider weekly low-dose decitabine and weekly venetoclax (metronomic dosing) in frail patients with high-risk MDS?
I find the metronomic dosing regimen of decitabine + venetoclax in high-risk myeloid malignancies (particularly TP53-mutated malignancies) very intriguing but have used the regimen sparingly thus far in the absence of randomized data supporting its use.When thinking about higher-risk MDS, we have da...
How do you view epcoritamab + R² in an older or frail patient with follicular lymphoma who would otherwise be a candidate for additional treatment after progresion on first line therapy?
Older and frail patients often derive less benefit from repeated chemotherapy as cumulative toxicity becomes increasingly important. ER2 offers the potential for a highly effective chemotherapy-free approach while maintaining an acceptable safety profile, but I think careful patient selection is ess...
What criteria is needed in relapsed/refractory B-cell ALL to choose CAR-T therapy over conventional stem cell transplant as destination therapy?
Currently, there are no standard criteria used to choose CAR-T over conventional stem cell transplant as destination therapy. However, there are many factors that often push us in one direction or the other. As we learn more about outcomes after CAR-T cell therapy, there are many factors we know are...
Would you treat patient with early stage unfavorable classic Hodgkin lymphoma with 6 cycles instead of 4 cycles of Nivo-AVD to avoid mediastinal radiation in young female?
I would tailor the number of cycles to the clearance of PET positivity. If one is considering stopping at 4 cycles, I would do a PET scan after 2 cycles and only stop at 4 if it was negative. If it is positive after 2 cycles, I would repeat the PET scan after 4 cycles. If it is still positive, an al...