Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you treat primary refractory diffuse large B cell lymphoma in elderly patients with good performance status?
In general, age (by itself) is not a limitation for most of the available therapies for DLBCL elderly patients. Comorbidities and performance status are what drive the decision of what to use as next therapy. I usually recommend all the approved therapies for RR DLBCL. My limit for autologous transp...
When can abdominal surgery be safely performed for presumptive ovarian cancer in a patient with recent pulmonary emboli?
In general, the standard approach is to try to wait as long as possible after the thrombotic event, at the very least three months. This may not be possible, we then reduce that time interval to one month. Given the urgent nature of the surgical intervention, one approach is to wait one month and co...
What is the indication for phlebotomy in compound heterozygous hemochromatosis?
The indication for phlebotomy is proven or strongly suspected iron overload. The likelihood of expression in these individuals is low. An elevated ferritin is often due to reasons other than iron overload such as fatty liver or alcohol intake. I usually do a liver ultrasound in this circumstance. If...
How would you work up and manage persistent lymphopenia in an asymptomatic patient?
Simple answer: refer to an immunologist, as this degree of lymphopenia is quite likely to represent a serious immunodeficiency. I would also send a next generation sequencing panel of immunodeficiency/immunoregulatory genes to be in process while awaiting the immunology consultation. Long answer (fr...
How would you manage a patient pre-operatively with a prolonged PTT that does not correct on mixing, with lupus anticoagulant testing that is abnormal by LA-PTT only?
Not all reagents/assays exhibit the same sensitivity (aka responsiveness) to lupus anticoagulants (LAC). In this case, there is evidence of LAC based on one assay, LA APTT. Often we see prolongation/inhibition in other assays e.g. APTT, but the phospholipid neutralization (PNP) step is not always di...
Do you screen adults in your practice with sickle cell disease for silent cerebral infarcts?
The details of the ASH guidelines regarding adults are complex. It was not my practice to screen all patients. More than 50% of adults have silent infarction. Screening requires MRI and this, according to the guidelines, needs careful attention to many details before it is reliable. There are no pro...
Would you restart prophylactic anticoagulation in a patient with a history of unprovoked PE who received short term anticoagulation with a prior physician?
The decision on duration of anticoagulation should balance the risk of hemorrhage vs risk of recurrent VTE. The annual risk of recurrence with unprovoked venous thromboembolism (VTE) is definitely higher than provoked VTE and seems to be higher in males than females.According to one study (Rodger et...
Do you routinely prophylactically anticoagulate patients undergoing systemic chemotherapy outside of the perioperative period?
No, I don’t routinely advise prophylactic anticoagulation for outpatients with gynecologic malignancies while on systemic chemotherapy who have not recently undergone surgery. However, such treatment may be considered for gynecologic cancer patients who are at high risk for venous thromboembolic dis...
During induction therapy for acute leukemia, when do you decide to discontinue the antimicrobial prophylaxis?
Antimicrobial prophylaxis (PPX) during treatment of acute leukemia can take several forms, and it is not always directly associated with blood counts.Fungal PPXDuring induction for AML, there are randomized data supporting posaconazole over fluconazole or itraconazole (Cornely, et al. New Engl J Med...
How do you utilize immunoglobulin testing to affect treatment decisions in patients with myeloma?
Most of the time, I correlate the type of Ig the patient has with the serum M protein and Free light chain to see if they are responding or progressing (most of the time it will correlate); the only exception is patients who are known with IgA type; most of the time the serum M -protein might not co...