Jorge Montemayor

MD🩺| Hematology fellow

[Jorge Montemayor @jorgelmm15]

Tomar lo que venga y convertirlo en brillo

[Ahmed Kotb @AhmedKo45911157]

📊#CD3xCD20 #Bispecifics in #Lymphoma

🧬Mosunetuzumab: FL ORR80%, CR 60% | DLBCL ORR42%, CR 24%
🧬Glofitamab: FL ORR 81%, CR 70% | DLBCL ORR 52%, CR 39%
🧬Epcoritamab: FL ORR 82%, CR 63% | DLBCL ORR 63%, CR 39%
🧬Odronextamab: FL ORR 80%, CR 73% | DLBCL ORR 52%, CR 31%
💡for R/R

[JAMA @JAMA_current]

Absolute iron deficiency affects approximately 2 billion people worldwide.

This narrative review examines the screening, diagnosis, and treatment of adults with absolute iron deficiency without anemia and iron-deficiency anemia. https://t.co/JRDMdhXJjT

[JAMA @JAMA_current]

Immune thrombotic thrombocytopenic purpura (iTTP) is an immune-mediated disorder characterized by thrombocytopenia and microangiopathic hemolytic anemia.

Learn more in this Review. https://t.co/YQF7gIkUu8

[Michelle🩸 @morcossandino]

🧵 1/9
📢 Just published!
"Advances in the Treatment of AML: Implications for Low- and Middle-Income Countries"
🔓 Open access: https://t.co/3dQONA8BEx
🧬 This thread breaks down key insights—and how they can help improve AML care in resource-limited settings.

[Ahmed Kotb @AhmedKo45911157]

Ph+ ALL Without Chemo? Yes!
📆 From 2000–2024, trials show:
✔️ Imatinib or dasatinib + steroids = remission
✔️ Adding blinatumomab boosts outcomes
✔️ 2024: D-ALBA 5-yr OS 75–80% with TKI + blina only, no chemo/transplant!
✔️ Ponatinib + blina = chemo-free, immune-driven remission

[Ahmed Kotb @AhmedKo45911157]

📊 First-line Tx in extranodal #PTCL (ESMO/EHA):
🟢 BIA-ALCL: Surgery ± ISRT
🔵HSTCL: Non-CHOP ChT → Auto-HSCT
🔴 ENKTL: CRT (I–II) / Sintilimab–GEMOX (III–IV)
🟠 EATL: Fit → CHOEP ± HSCT | Frail → CHOP-like
🟣METL: ChT
⚪ iTLPD: Watch & wait / ISRT / Surgery if risk
#Lymphoma

[NEJM @NEJM]

Patients with a prothrombotic clinical course often associated with thrombocytopenia may have a monoclonal paraprotein, even at low levels, that activates platelets by binding to platelet factor 4. Learn more in a Brief Report: https://t.co/te1RtMJ17B

#Hematology

[Dr. Chokri Ben Lamine @abouabdrahman0]

📢 Comprehensive Review: Triple Intrathecal (IT) Chemotherapy in Hematology 💉🩸

📝 Overview:
🔹 Triple IT Chemo (TIT) = Methotrexate (MTX) + Cytarabine (Ara-C) + Hydrocortisone
🔹 Used for CNS prophylaxis & treatment in leukemia & lymphoma
🔹 Essential for high-risk CNS disease, preventing relapse 🚑

⸻

📌 Composition & Dosing of Triple IT Chemo

✔️ Methotrexate (MTX) – 12–15 mg (Folate antagonist, main CNS agent)
✔️ Cytarabine (Ara-C) – 30–50 mg (Inhibits DNA synthesis)
✔️ Hydrocortisone – 30 mg (Reduces inflammation & arachnoiditis risk)

📌 TIT is usually administered in 3–6 mL preservative-free saline

⸻

📌 Indications for Triple IT Chemotherapy

🛡️ CNS Prophylaxis (To prevent CNS involvement)
✔️ Acute Lymphoblastic Leukemia (ALL) – High-risk & standard-risk
✔️ Acute Myeloid Leukemia (AML) – High-risk cases (e.g., MLL-r, WBC >100K, CNS1 with high-risk features)
✔️ Lymphomas – Burkitt, Primary CNS Lymphoma, DLBCL with high CNS-IPI
✔️ High-risk Myelodysplastic Syndrome (MDS) with blasts & CNS suspicion

🚑 CNS Disease Treatment (CNS3)
✔️ CNS-positive ALL/AML (CSF WBC ≥5 + blasts)
✔️ Lymphomatous Meningitis (PCNSL, DLBCL, Burkitt)
✔️ CNS relapse post-HSCT

⸻

📌 IT Chemotherapy Schedule & Frequency

🟢 Prophylactic Triple IT Schedule (B-ALL, High-Risk Lymphoma):
✔️ Induction: 1–2 IT doses per week for 2–4 weeks
✔️ Consolidation: Every 2–4 weeks
✔️ Maintenance: Every 12 weeks (ALL regimens)

🔴 CNS-Positive Disease (CNS3 ALL, Lymphomatous Meningitis):
✔️ Induction Phase: 2–3 IT doses per week until CSF clearance
✔️ Consolidation: Weekly IT chemo for 4–6 weeks
✔️ Maintenance: Monthly IT chemo (if no radiation planned)

⚠️ Ommaya Reservoir Placement in cases requiring frequent LPs (e.g., CNS leukemia relapse, PCNSL)

⸻

📌 Administration Considerations & Technique

🟢 Best Practices for IT Chemo Administration:
✔️ Atraumatic needle (Reduces post-LP headache)
✔️ Slow injection (1 mL per 20 seconds) 💉
✔️ Patient supine for 1 hour post-LP
✔️ Avoid IV contrast & nephrotoxic drugs on the same day as IT MTX
✔️ Pre-medicate with Ondansetron for nausea

🔴 Avoid These Errors:
🚫 Traumatic LP (≥10 RBCs in Tube 1 & 4) – Increases CNS relapse risk
🚫 LP in thrombocytopenic patients (PLT <50K) – Pre-transfuse before procedure
🚫 Concurrent IV contrast if using IT MTX – Risk of acute kidney injury 🚨

⸻

📌 Side Effects & Management

⚠️ Major Toxicities:
🧠 Neurotoxicity (Seizures, Encephalopathy, Aseptic Meningitis)
✔️ Prevent with Hydrocortisone, slow injection, and IV hydration
📉 Cytopenias (MTX & Ara-C myelosuppression)
✔️ Monitor CBC, dose adjust if needed
🚨 Chemical Arachnoiditis (Fever, Headache, Neck Stiffness)
✔️ Prevent with Hydrocortisone & pre-hydration

⸻

📌 Clinical Pearls & Practical Tips

🔹 TIT is superior to single-agent IT chemo for high-risk patients 🏆
🔹 Use in CNS3 ALL until CSF clearance is confirmed x2 LPs
🔹 Ommaya is beneficial for frequent IT chemo administration
🔹 TIT can be safely combined with IV HD-MTX in lymphoma protocols
🔹 Monitor closely for neurotoxicity, especially in elderly patients

📌 Key Takeaways:
✔️ TIT = More effective than single-agent IT chemo in CNS prophylaxis
✔️ Essential for ALL, Burkitt, DLBCL with CNS involvement
✔️ Hydrocortisone reduces neurotoxicity risk
✔️ Ommaya reservoir for frequent IT therapy reduces LP burden

#TripleIT #CNSLeukemia #Lymphoma #IntrathecalChemo #Hematology #Oncology #MedTwitter

[Dr. Chokri Ben Lamine @abouabdrahman0]

🚨 Comprehensive Management of Severe Bleeding on Oral Anticoagulation 🚨

Managing severe bleeding in anticoagulated patients requires a systematic approach to ensure timely intervention and patient safety.

⸻

🩸 Step 1: Identify Severe Bleeding

Severe bleeding is life-, limb-, or organ-threatening, including:
🔹 Hemodynamic instability (e.g., gastrointestinal or retroperitoneal bleeding)
🔹 Intracranial bleeding
🔹 Limb-threatening hematoma (e.g., compartment syndrome)

⸻

🛑 Step 2: Initiate Resuscitation & Supportive Measures

✅ Hold anticoagulant therapy immediately
✅ Fluid resuscitation (crystalloids, blood products as needed)
✅ Local hemostasis (compression, sutures)
✅ Interventional procedures (embolization, surgery)
✅ Adjunctive therapy (tranexamic acid (TXA), clotting factor support)

⸻

🩺 Step 3: Assess for Clinically Significant Anticoagulant Effect

Warfarin: Check INR immediately!
🔸 INR ≤1.2: No significant effect
🔸 INR 1.3–1.5: Unlikely to be significant
🔸 INR >1.5: Likely significant

Direct Oral Anticoagulants (DOACs):
🔸 Dabigatran: Thrombin time (TT), dilute thrombin time
🔸 Apixaban, Rivaroxaban, Edoxaban: Anti-Xa levels, drug-specific assays

⚠️ Do not delay treatment while awaiting lab results if bleeding is critical!

⸻

💉 Step 4: Administer Reversal or Hemostatic Therapy

If severe bleeding AND significant anticoagulant effect → reversal therapy required!

🔹 Warfarin:
✅ Vitamin K (5–10 mg IV) + 4-factor PCC (25-50 IU/kg based on INR)

🔹 Dabigatran:
✅ Idarucizumab (Praxbind) 5 g IV (2 x 2.5 g boluses within 15 min)
✅ Activated PCC or 4-factor PCC if idarucizumab unavailable

🔹 Factor Xa Inhibitors (Apixaban, Rivaroxaban, Edoxaban):
✅ Andexanet alfa (if available) – dose depends on last dose timing
✅ 4-factor PCC (2000–3000 IU) if Andexanet alfa unavailable

⚠️ Monitor closely for rebound anticoagulation after reversal!

⸻

🔄 Step 5: Restart Anticoagulation Post-Bleeding

Restarting anticoagulation should be carefully assessed:
✔️ Has bleeding stopped?
✔️ Is anticoagulation still indicated (e.g., AF, DVT/PE, prosthetic valve)?
✔️ Does the benefit outweigh the risk?
✔️ Has shared decision-making with the patient/caregiver occurred?

⸻

🛡️ Step 6: Prevent Future Bleeding

🔸 Optimize anticoagulant selection & dosing
🔸 Monitor renal/liver function (affects drug clearance)
🔸 Review medications (interactions with antiplatelets, NSAIDs)
🔸 Manage modifiable bleeding risks (hypertension, ulcers, falls)
🔸 Consider DOACs over warfarin for reduced bleeding risk

📌 Takeaway: Rapid assessment, reversal, and a structured approach are crucial in managing severe bleeding in anticoagulated patients!

#Hematology #Anticoagulation #BleedingManagement #PatientSafety

[Dr. Chokri Ben Lamine @abouabdrahman0]

📢 Guide to Switching Anticoagulants 📢
Clinicians often face the challenge of transitioning between anticoagulants. Here’s a simplified breakdown with clinical pearls! 🧵👇

🔄 Warfarin to NOACs (Rivaroxaban, Apixaban, Dabigatran)

✅ Stop warfarin & start:
🔹 Rivaroxaban when INR <3.0
🔹 Apixaban when INR <2.0
🔹 Dabigatran when INR <2.0

💡 Pearl: Warfarin has a long half-life, so overlap may be needed in high-risk cases!

🔄 Warfarin to LMWH

✅ Start LMWH when INR <2.0 for DVT/PE treatment
✅ For stroke prevention, wait until INR <2.5

💡 Exam Tip: If renal impairment exists, plasma concentrations may be higher than expected—monitor closely! 📉

🔄 LMWH to NOACs

✅ Discontinue LMWH & start:
🔹 Rivaroxaban 0–2 hrs before next LMWH dose
🔹 Apixaban/Dabigatran at next scheduled LMWH dose

💡 Pearl: Timing matters—prevent thrombosis by ensuring minimal interruption! ⏳

🔄 NOACs to Warfarin

✅ Overlap required 📊
🔹 Rivaroxaban: Stop when INR is in range
🔹 Apixaban: Continue for 2 days, stop when INR ≥2.0
🔹 Dabigatran: Based on CrCl—stop 2-3 days before

💡 Clinical Tip: Dabigatran increases INR! Measure INR 2 days after stopping to avoid false elevation! 🚨

🔄 Switching Between NOACs

✅ Direct Switch ⏩
🔹 Discontinue Rivaroxaban/Apixaban/Dabigatran & start new NOAC at the next scheduled dose

💡 Pearl: NOACs have fast onset—no need for overlap! 🚀

🔎 Key Takeaways

🔹 Warfarin needs INR monitoring when switching
🔹 LMWH requires careful timing
🔹 NOACs allow direct switch at next dose
🔹 Dabigatran + INR = tricky—be cautious!

💡 Clinical Pearl: Always assess renal function before switching! 🩺

#MedEd #Anticoagulation #NOACs #Warfarin #Hematology

[Liga Femenil BBVA @LigaBBVAFemenil]

QUÉ COSAAAA
QUÉ GOLAZOOOO
QUÉ FUTBOL

🎩 JACQUELINE OVALLE, en mayúsculas. 🎩

#SomosDesafiantes⚡️

[Nico Gagelmann @NicoGagelmann]

Let's learn hematology in 2025🩸

Day 48: approach to Burkitt lymphoma

[Dr. Chokri Ben Lamine @abouabdrahman0]

📢 Diagnostic Algorithm for Hyperferritinemia

🩸 Hyperferritinemia
🔹 Ferritin >200 ng/mL (♀) or >300 ng/mL (♂)
🔍 Step 1: Check Transferrin Saturation

✅ TSAT >45%
🔬 HFE Gene Testing
🧬 HFE Genotypes (C282Y/C282Y, C282Y/H63D, C282Y/S65C)?
➡️ Yes → ⚠️ Hereditary Hemochromatosis (HH)
🔍 Liver MRI (T2 Iron Quantification) or Biopsy if Fibrosis Risk*
➡️ No → 🔬 Consider Non-HFE Hemochromatosis
🔎 Liver MRI ± Biopsy

🚫 TSAT <45%
🩺 Look for Secondary Causes
🔥 Inflammatory Causes
•Metabolic Syndrome
•Alcohol Use
•Autoimmune Disease
•Active Cancer
•Systemic Infection
•Metabolic Dysfunction–Associated Steatotic Liver Disease
💊 Treat & Recheck

🍷 Alcohol-Related?
⏳ Recheck Ferritin in 6-12 Weeks
📊 Persistent Elevation? → 🔍 Liver MRI

🩸 Secondary Iron Overload?
•Liver Disease (Non-HH)
•Frequent IV/Oral Iron
•Blood Transfusion
•Hemodialysis/Hemolysis
•Hematologic Disorders
•Rare Genetic Disease

#Hematology #Hyperferritinemia #Hemochromatosis #IronOverload

[ESPN.com.mx @ESPNmx]

🇲🇽 ¡GOOOL DE SANTI GIMENEZ!
🇲🇽 ¡GOOOL DE SANTI GIMENEZ!

MARCA EN SU DEBUT DE SERIE A

[cinesthetic. @TheCinesthetic]

The opening scene of Severance Season 2 took five months to film, with Adam Scott revealing he drew inspiration from Tom Cruise’s iconic running.

[Dr. Chokri Ben Lamine @abouabdrahman0]

Comprehensive Guide: Monitoring and Managing Methotrexate (MTX) Levels after High-Dose Methotrexate (HDMTX) in DLBCL 🧵

🔬 High-dose methotrexate (HDMTX) is critical for CNS prophylaxis or treatment in diffuse large B-cell lymphoma (DLBCL).

1️⃣ Key Goals of Monitoring 🎯
•Prevent MTX toxicity:
•Nephrotoxicity 🚨.
•Hepatotoxicity ⚠️.
•Myelosuppression 🔻.
•Ensure timely MTX clearance for safety.
•Optimize leucovorin rescue timing and dosage.

2️⃣ MTX Levels Monitoring Protocol 📉
1.Timing of Levels:
•First MTX level: 24 hours after starting infusion.
•Repeat at 48 hours, 72 hours, and until level <0.05 μmol/L.
2.Critical Thresholds:
•24 hours: <10 μmol/L ✅.
•48 hours: <1 μmol/L ✅.
•72 hours: <0.1 μmol/L ✅.

3️⃣ Factors Affecting MTX Clearance ⚡
1.Renal Function:
•MTX is cleared renally; impaired function delays clearance 🛑.
2.Hydration:
•Alkaline diuresis (urine pH >7.0) prevents MTX crystallization 💧.
3.Drug Interactions:
•NSAIDs, penicillins, and PPIs interfere with MTX clearance ⚠️.

4️⃣ Leucovorin Rescue Protocol 💊
•Purpose: Prevent toxicity by rescuing normal cells.
•Dose:
•MTX >10 μmol/L (24h): 100 mg/m² every 6 hours.
•MTX 1–10 μmol/L (24–48h): 50 mg/m² every 6 hours.
•MTX <1 μmol/L: 10–15 mg/m² every 6 hours.
•Continue until MTX <0.05 μmol/L.

5️⃣ Management of Delayed Clearance 🚨
1.Prolonged High MTX Levels (>1 μmol/L at 48 hours):
•Increase leucovorin dose and frequency.
•Intensify hydration and alkalinization (add bicarbonate if urine pH <7.0).
2.Severe Delayed Clearance (>10 μmol/L at 48 hours):
•Consider glucarpidase:
•Dose: 50 units/kg IV.
•Rapidly clears extracellular MTX within hours.

💡 After glucarpidase, ignore standard MTX levels for 48 hours (false elevation due to metabolites).

6️⃣ Monitoring for Toxicity 🩺
•Renal: Creatinine daily, urine pH every 4–6 hours.
•Hematological: WBC, hemoglobin, platelets daily.
•Liver: AST, ALT, bilirubin.
•Clinical Symptoms: Mucositis, fatigue, confusion, oliguria.

7️⃣ Exam Pearls 📚
1.Risk Factors for MTX Toxicity:
•Dehydration 💧.
•Renal dysfunction 🚩.
•Drug interactions ⚠️.
2.Glucarpidase Indications:
•MTX >10 μmol/L at 48 hours or creatinine doubles.
3.Hydration Recommendations:
•3L/m²/day IV hydration with sodium bicarbonate is essential.
4.Urine Alkalinization:
•Maintain pH >7.0 to prevent MTX precipitation and nephrotoxicity.

8️⃣ Suggested Slide Structure for Meetings

Slide TopicKey Content
Case OverviewPatient age, DLBCL subtype, HDMTX purpose.
MTX LevelsLevels at 24h, 48h, 72h, trend chart 📈.
ManagementLeucovorin dosing, hydration protocol.
ToxicityMonitoring labs, renal/liver trends.
ComplicationsDelayed clearance, glucarpidase timing 🚨.
Learning PointsGuidelines, practical pearls 🩺.

#Hematology #Lymphoma #HDMTX #MTXManagement #Oncology

[AmericanJournalofHematology @AjHematology]

The Mayo genetic risk models offer pre-treatment and response-based prognostic tools for newly diagnosed #AML treated with Ven-HMA
Open access: https://t.co/bQMQbJCacm
#LeuSM @AntoineNSaliba

[NEJM @NEJM]

Original Article: Clearance of Driver Mutations after Transplantation for Myelofibrosis https://t.co/qiCmvCJaDi

#Hematology

[Keith Siau @drkeithsiau]

Drinking more than 3 cups of coffee, especially in the mornings rather than throughout the day, may be one of the easiest ways to increase survival! Hurray for coffee…in the mornings 🤪☕️

https://t.co/7q0jludeHv

[Uriel Suárez @UsuarezMD]

Noninfectious Causes of Persistent Fever in Neutropenic Patients With Hematologic Malignancy

https://t.co/4P3BPBLgyb