Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you treat a patient with POEMS syndrome with severe debilitating neuropathy?
This is an important question. Peripheral neuropathy is one of the mandatory criteria for a diagnosis of POEMS syndrome, and can range from mild paresthesias to devastating, wheelchair-bound neuropathy (Dispenzieri, PMID 37732822). What makes POEMS uniquely gratifying is that effective therapy can l...
In patients with Philadelphia-negative ALL who are transplant ineligible, is there any data to guide the duration of maintenance POMP therapy?
To my knowledge, there have not been any prospective trials in the modern era that specifically address the issue of the duration of maintenance therapy in adults with ALL.Most regimens that have been studied provide a timeframe over which maintenance therapy should be administered, and nearly all h...
What is your approach to bone imaging in MGUS?
Excellent question. For low-risk MGUS (M-spike <1.5 g/dL, normal serum free light chain ratio, and an IgG type protein), it is reasonable to forego any bone imaging in the absence of any relevant bone-related symptoms. The rate of bone involvement in patients with an M-spike of 1.5 g/dL was noted to...
How do you approach the management of a patient with symptomatic iron deficiency anemia who is intolerant of iron?
Oral iron will not work. I would bet my last dollar there was no anaphylaxis but rather an imprudently treated minor infusion reaction which is the cause of ostensible “anaphylaxis” over 99% of the time. You can’t verify that it was real because I can assure you: It was not. They did not do a trypt...
Do you routinely refer young patients with iron deficiency anemia for GI evaluation?
The answer is no, I do not. However, if after iron repletion deficiency persists, then I do. But as for pregnancy, unless there has been a precipitous and proven drop, I would definitely not do a GI workup during pregnancy.
How would you manage symptomatic iron deficiency in patients with PV on frequent phlebotomies?
While iron deficiency by itself is not harmful, if someone has symptomatic iron deficiency, you could consider them intolerant to phlebotomies, and start a cytoreductive agent. Then, over time they can replete their iron stores. In some patients who are very symptomatic from their iron deficiency, I...
How soon after initiating oral anticoagulation therapy for atrial fibrillation can it be interrupted for surgery or procedures?
As with most things medical, multiple answers. If a patient walks into my office for preOp "clearance" and behold, they are in atrial fib, but asymptomatic, then it would depend on the urgency of their surgery. If elective, then you have time to work up his atrial fib and look for a reversal cause (...
For a patient with May-Thurner syndrome and DVT, would you recommend anticoagulation for 3-6 months or indefinitely?
This is a very good question, there is little data on this and there are only a few case series. One case series of 8 patients showed a 25% risk of recurrence in one year with May-Thurner syndrome but too small of a sample to really know what the risk is, plus this probably included a heterogenous m...
For patients with newly diagnosed VTE on IV heparin planned for transition to DOAC, would you start at the loading or maintenance DOAC dose?
Agree with Dr. @Dr. First Last. In the clinical trials that led to rivaroxaban and apixaban approval, many patients had 2 days of injected anticoagulant first to arrive at successful outcomes leading to DOAC approval. I suggest IV heparin until hemodynamically normal (for PE), sq LMWH for a dose or ...
How are you deciding between available third line therapies for post-transplant relapsed DLBCL?
If a patient relapses after an autologous stem cell transplant and is a candidate for CAR T-cell therapy, I would proceed with CAR T-cell therapy given longer follow up compared to bispecific antibodies, and thus a portion of the patient can achieve a durable complete response. For patients that rel...