Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Are there any alternative, hypofractionated RT courses for patients with DLBCL that can be used during the COVID-19 pandemic?
ILROG recently came out with guidelines pasted below: Synopsis of ILROG Recommendations for Administering Radiotherapy for Hematological Malignancies During Emergency Conditions of the COVID-19 Pandemic • We are facing an increased demand for RT to substitute or complement systemic therapy deemed i...
How do you counsel patients on the risk of thromboembolic complications with use of immunotherapy in NSCLC?
Patients with metastatic lung cancer are at increased risk of thromboembolic events with an estimated frequency of 13.9% (Connolly et al., PMID 23026639). Preclinical data show that PD-1/PD-1 pathway blockade may lead to increased levels of pro-inflammatory cytokines and T cell driven progression an...
Does anyone utilize P2Y12 assays to determine if clopidogrel may be ineffective when used for DAPT?
Yes, I use P2Y12 assays in two distinct settings. Medical management: If a patient on clopidogrel mono/dual therapy has disease progression with ICAD or experiences a recurrent ischemic event, I obtain a P2Y12 assay to assess responsiveness. This helps guide the decision to switch to ticagrelor and ...
What factors do you consider before discharging an MGUS patient from hematology clinic to safely follow with outpatient PCP?
In general, I follow the risk stratification referenced in the Mayo Clinic's recent review, and I tend to think about a clinic discharge from hematology if they have low-risk MGUS, i.e., serum M protein <1.5 gm/dL, IgG subtype, normal FLC ratio (0.26-1.65).I then use the Lee Index to estimate the pa...
What is your approach to chronic non-immune mediated thrombocytopenia management in children?
There are whole textbook chapters on this topic, and we use a variant of this question to review the differential diagnosis of thrombocytopenia with our fellows as a didactic exercise. So I take from this question, which is an important one, what might be a framework to consider the differential dx ...
Besides GI evaluation and testing for celiac, what other testing do you consider with a patient with unexplained Iron deficiency anemia and a negative bleeding history?
I assume this question comes after endoscopies are negative. Autoimmune gastritis is 30 times more frequent than celiac disease. So anti-parietal cell antibody should be ordered. >30 likely, >50 usually diagnostic. If still negative, a history of long-duration therapy for reflux will explain iron de...
Would you stop current immunosuppressive therapy or delay starting immunosuppressive therapy in a patient with aplastic anemia who has been infected with COVID-19?
Not much is known yet about this specific situation—but our growing experience here in New York City suggests it may be safe. We have had several post-BMT patients who were on immune suppression for GVHD become COVID positive who have not had significant problems. Also, we have now treated 8-10 pat...
How do you approach a patient with IgM monoclonal gammopathy associated with severe neuropathy of unclear etiology?
I usually confirm if the patient does not have AL Amyloidosis or POEMS, and as part of work up for IgM MGUS, I order MYD 88 mutation. If all are negative and I still believe that neuropathy is caused from his/her MGUS, you can try IVIG for the neuropathy as a trial (of course after using gabapentin,...
Would you recommend anticoagulation prophylaxis for a pediatric patient admitted with COVID-19?
COVID-19 disease in children seems to be less severe than adults based on the current literature and our personal experience at Children's Hospitals. Among adults, the coagulopathy is beginning to be described with elevated inflammatory markers and other markers of coagulation activation, including ...
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...