Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your clinical threshold for treating a potential monoclonal gammopathy of thrombotic significance?
I strongly advise against routine screening for monoclonal gammopathy in patients with thrombosis. The incidence of MGUS, particularly in older patients, is relatively high and so the signal-to-noise ratio in this setting will be very low. In a patient with recurrent thrombosis and thrombocytopenia ...
How do you manage high-risk MDS IB2 patients on HMA and venetoclax who develop an acute stroke requiring antiplatelet therapy?
Not sure of the current platelet count? Not sure of the age of the patient.Will still use antiplatelet therapy for acute stroke as advised.Support with platelet transfusion as needed for platelet count <20. Hopefully patient responds to HMA and venetoclax, and platelet counts improve.If in CR by mar...
How would you manage aplastic anemia refractory to multiple agents?
If indeed the patient has been treated with all reasonable alternatives to BMT, the choices are 1) watch and wait with supportive care or 2) bone marrow transplantation. I understand the reluctance of transplanting someone in their 70s with aplastic anemia; however, we do this routinely in patients ...
What is your preferred therapy for MDS/MPN with significant leukocytosis and neutrophilia?
Depends on blast count, cytogenetics, and molecular test results, age of patient, performance status, comorbidities, etc. To bring the white count down can temporarily start with hydroxyurea. would use induction chemo versus HMA +/- venetoclax to achieve at least a partial response. can be a candida...
How would you approach adjusting nivo+AVD therapy for advanced Hodgkin lymphoma if a patient develops treatment limited immunotherapy toxicity?
BV-AVD-related transaminitis is relatively common; however, even with Nivo-AVD, transaminitis is frequently observed, albeit at a lower frequency. Most of these events are self-limited and grade 1-2. Depending on the stage and severity of the event, dose holds can be employed; however, adverse event...
What is your re-immunization strategy after auto SCT for patients with myeloma on dara/len maintenance?
We do the same vaccination sequence according to BMT/CTN, whether they are on maintenance dara or not. Here is our schedule Post autologous SCT vaccine Interval Date Vaccine Yearly Flu Vaccine 3-month post-transplant Pneumovax 20, Hib, hep A/hep B, polio, TDap, Shingrix 6 months post-transplant Pneu...
How would you define your radiation treatment volume for a primary diffuse large B-cell lymphoma of the L4 vertebral body that had a complete response to chemotherapy?
For a primary DLBCL involving only the L4 vertebral body with a CR after chemotherapy, we would include just the involved L4 vertebral body. There is no need to include one vertebral body above and below. Effort should be made to reduce excess dose to the bowel and adjacent bone marrow with either a...
How do you counsel an otherwise healthy patient on how soon they can go back to moderate exercise after a bilateral pulmonary embolism?
Generally, the approach is to have the patient start their exercise regimen at a lower intensity and gradually increase it based on their tolerance.
Would you use argatroban or citrate catheter lock in a patient with ESKD and HITT?
I would use 4% citrate. I have no experience using argatroban as a catheter lock solution, but have significant experience using 4% citrate solution. For our inpatients, we only use 4% citrate solution (and have done so for many years). While I believe you can buy prefilled 4% citrate syringes comme...
What is your approach to further work-up and management of neutropenia in patients with SLE/RA overlap?
This is an interesting situation that comes up in the routine evaluation of patients with rheumatoid arthritis and other autoimmune syndromes. The normocellular bone marrow suggests a peripheral destruction, in general, and raises some concerns for antibodies directed against neutrophils. These are ...