Incidence of Heparin-Induced Thrombocytopenia in Patients With Newly Implanted Mechanical Circulatory Support Devices.

BACKGROUND: Heparin exposure and device-related thrombocytopenia complicate the diagnosis of heparin-induced thrombocytopenia (HIT) in patients receiving mechanical circulatory support (MCS). To improve anticoagulation management for patients with newly implanted MCS devices, incidence of confirmed HIT needs to be further characterized. OBJECTIVES: The purpose of this study is to describe the incidence of HIT and clinical utility of the 4Ts score in patients with newly implanted MCS devices. METHODS: This is a retrospective analysis of MCS patients receiving unfractionated heparin from 2014 to 2017. The primary end point was incidence of laboratory-confirmed HIT. Strong positive, likely positive, low probability, and negative HIT categories were established based on heparin-induced platelet antibody (HIPA) and serotonin release assay (SRA). Secondary end points include characterization of platelet trends, argatroban use, incidence of HIT among each of the MCS devices, and utility of 4Ts score. RESULTS: A total of 342 patient encounters met inclusion criteria, of which 68 HIPA tests and 25 SRAs were ordered. The incidence of HIT was 0.88% (3/342) and 4.4% (3/68) in patients with suspected HIT. Of the 68 HIPA tests, 3 (4.4%) were considered strong positive and 3 of the 25 SRAs were positive. Median 4Ts score was 4 [2.5-4] and optical density 0.19 [0.11-0.54]. The positive predictive value for the 4Ts score was 0.15 (CI = 0.03-0.46) and negative predictive value, 0.93 (CI = 0.82-0.98). CONCLUSION AND RELEVANCE: HIT occurs infrequently with newly implanted MCS devices. The 4Ts score appears to have a high negative predictive value for ruling out HIT.

Identifying opportunities to advance practice at a large academic medical center using the ASHP Ambulatory Care Self-Assessment Tool.

PURPOSE: The use of the ASHP Ambulatory Care Self-Assessment Tool to advance pharmacy practice at 8 ambulatory care clinics of a large academic medical center is described. SUMMARY: The ASHP Ambulatory Care Self-Assessment Tool was developed to help ambulatory care pharmacists assess how their current practices align with the ASHP Practice Advancement Initiative. The Henry Ford Hospital Ambulatory Care Advisory Group (ACAG) opted to use the "Practitioner Track" sections of the tool to assess pharmacy practices within each of 8 ambulatory care clinics individually. The responses to self-assessment items were then compiled and discussed by ACAG members. The group identified best practices and ways to implement action items to advance ambulatory care practice throughout the institution. Three recommended action items were common to most clinics: (1) identify and evaluate solutions to deliver financially viable services, (2) develop technology to improve patient care, and (3) optimize the role of pharmacy technicians and support personnel. The ACAG leadership met with pharmacy administrators to discuss how action items that were both feasible and deemed likely to have a medium-to-high impact aligned with departmental goals and used this information to develop an ambulatory care strategic plan. This process informed and enabled initiatives to advance ambulatory care pharmacy practice within the system. CONCLUSION: The ASHP Ambulatory Care Self-Assessment Tool was useful in identifying opportunities for practice advancement in a large academic medical center.

Older adults' perspectives on naturopathic medicine's impact on healthy aging.

CONTEXT: High rates of complementary and alternative medicine (CAM) utilization among older adults are of interest because studies suggest relationships among CAM, self-care, and healthy lifestyle. These potential relationships are of particular interest because of the contribution of self-care in maintaining physical, emotional, and spiritual health as key strategies to successful aging. Naturopathic medicine (NM) is a type of primary care CAM used by older adults, yet little is known about older adults' use of NM or its role in healthy aging. OBJECTIVES: We sought to examine perceptions about, and utilization of, NM and the experience of addressing health and wellness as part of the aging process. DESIGN: Phenomenology-based qualitative inquiry. SETTING: A total of 13 community-based clinics affiliated with a naturopathic medical school. PARTICIPANTS: A total of 47 adults aged 58-100 years. METHODS: Qualitative analysis of semi-structured focus groups with quantitative analysis of clinical administrative data. RESULTS: Over 2543 older adults used NM services affiliated with a natural academic clinic in Seattle in 2011 for diagnoses consistent with primary care: fatigue, anxiety, diabetes, diarrhea, and depression, in rank order. Participants reported they sought NM because it offered a different system of care aligned with their values. Themes included (1) feeling heard, (2) a focus on health education including prevention and self-care, and (3) feeling supported. Themes further distilled into optimal descriptive characteristics of patient-centered providers that may best support older adults' healthy aging. A final theme described barriers to further utilization.

Melanoma of the ear: results of a cartilage-sparing approach to resection.

Melanoma of the ear is often treated by composite resection of the skin and cartilage and, occasionally, by total auriculectomy. This review analyzes the oncologic, functional, and esthetic results of cartilage-sparing wide local excision for melanoma of the ear. This retrospective study reviewed patients with ear melanoma treated between 1997 and 2002. All patients were treated with cartilage-sparing wide local excision, and ears were reconstructed with skin grafts and/or local flaps. The majority of patients were men (16/18 patients) who ranged in age from 42 to 82 years. The most common sites of occurrence were the helical rim (7/18 patients) and the earlobe (6/18 patients). The average depth of invasion was 2.02 mm (range 0.4-6.0 mm). Sentinel lymph node biopsy was performed in 13 cases, of which only one was positive. The local control rate was 100 %, overall survival was 72 % (13/18 patients), and disease-specific survival was 89 % (16/18 patients). Average follow-up was 30.5 months (range 1-61). The rates for local control, overall survival, and disease-specific survival were excellent. These data indicate that for the majority of ear melanomas, cartilage-sparing wide local excision is an acceptable means of treatment.

Differential induction of branchial carbonic anhydrase and NA(+)/K(+) ATPase activity in the euryhaline crab, Carcinus maenas, in response to low salinity exposure.

The time course of induction of activity of carbonic anhydrase (CA) and Na/K ATPase, two enzymes that are central to osmotic and ionic regulation in the eyryhaline green crab, Carcinus maenas, was measured in response to a transfer from 32 to 10 ppt salinity. CA activity was low in all gills in crabs acclimated to high salinity. Activity was induced in the posterior three gills (G6-G9) starting at 96 hr following transfer to low salinity, with activity peaking at seven post-transfer. Na/K ATPase activity in posterior gills was already high in crabs acclimated to 32 ppt salinity, and it did not increase as a result of transfer to 10 ppt. Acclimation of crabs to hypersaline (40 ppt) conditions resulted in uniformly low levels of Na/K ATPase activity, and transfer from 40 ppt to 10 ppt stimulated a four-fold induction of activity in the posterior gills that was evident by seven days of low salinity exposure. Low salinity stimulates the activity of both enzymes, but a different degree of salinity change appears to be necessary to cause the induction of each enzyme. The Na/K ATPase activity is already high at a salinity (32 ppt) at which the crab is still an osmotic and ionic conformer. CA activity, however, even when expressed in low levels, is still present in excess of what is needed to supply counterions at a rate adequate to match the rate of active ion transport. It is possible that two strategies exist for the regulation of these two enzymes that coincide with the crab's intertidal and estuarine lifestyle: short-term modulation of activity of highly expressed enzyme (Na/K ATPase) and long-term modulation of enzyme concentration by changes in gene expression (CA). For all ranges of low salinity exposure, crabs undergo hemodilution, cell swelling, and subsequent cell volume readjustment as evidenced by the increase in concentration of TNPS in the hemolymph. This response takes place before the induction of enzyme activity, and it could serve as the initial signal in the induction pathway.