Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you advise mobility restrictions in a patient with Protein S deficiency and acute upper extremity DVTs but contraindications to anticoagulation (e.g., acute GI bleed) to reduce the risk of thrombus embolization?
This question is an interesting one and an incredibly specific scenario. I'll try to broaden the answer to cover a few more scenarios. So, the question gets at three elements: 1) Patient has an acute VTE, 2) Patient has a hypercoagulable state, 3) Patient has a contraindication to anticoagulation. S...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
How do you manage hyperhemolysis syndrome in a patient with life-threatening anemia and evidence of end-organ ischemia who requires emergent transfusion despite the risk of worsening hemolysis?
Any sudden-onset, rapid hemolysis could be encompassed by the term hyperhemolysis, for instance, following a mismatched transfusion, a delayed hemolytic transfusion reaction (DHTR), hemolysis triggered by an autoantibody, or a toxin in someone with G6PD deficiency or an infection in someone with sph...
How do you manage infection risk when using BTKi-chemoimmunotherapy combinations in MCL patients?
This is a broad question, but BTKi are used in younger/fit patients (TRIANGLE-like therapy, including cytarabine) and approved in combination with BR (acalabrutinib). Regarding the latter: bendamustine is known to be T-cell depleting and associated with zoster/HSV and risk of other viral infections....
In what scenarios do you use a chromogenic factor X assay in adjusting INR goals for patients on warfarin?
I do not use this method. It has been suggested that such assays be used in patients with lupus-type inhibitors who have significantly prolonged prothrombin times at baseline. In this setting, if the INR is "therapeutic," one would confirm an adequate warfarin effect if the factor X activity was in ...
Do you offer enasidenib with azacitadine in AML with an IDH2 mutation for patients ineligible for intensive induction chemotherapy?
I typically do not give enasidenib with azacitidine upfront for patients with AML with IDH2 mutation and ineligible for intensive induction chemotherapy. Based on the results of the VIALE-A study (DiNardo et al, NEJM 2020), I usually give venetoclax with azacitidine to those patients. In addition to...
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...
How would you approach mantle cell lymphoma in very elderly patients?
For patients who are very elderly, my approach depends on the patient's performance status, other comorbidities, disease features/disease behavior, and indications for treatment. There are patients with MCL who can be observed at diagnosis (those with leukemic non-nodal disease but also those with l...