A high-value cost conscious approach to minimize heparin induced thrombocytopenia antibody (HITAb) testing using the 4T score.

Heparin Induced Thrombocytopenia (HIT) is a serious complication from administration of heparin products. The 4T score is a validated pre-test probability tool to screen for HIT in hospitalized patients. As the negative predictive value (NPV) is very high further testing for HIT in patients with a low score can be avoided. Our objective was to determine trends at our hospital with respect to utilization of HIT antibody (HITAb) testing and evaluate economic burden from unnecessary HIT testing. A retrospective cohort review was performed on patients age 18 and above admitted to a tertiary care center from February 2013 to December 2014 who underwent HITAb testing. Surgical ICU patients were excluded. Patients were stratified into low, intermediate, and high risk for HIT based on the 4T model. Statistical analysis was performed using Chi square and regression models. Of 150 patients that underwent HITAb testing, 134 met inclusion criteria. 73 were male (54.47 %) and mean age was 55.50 ± 17.27 years. 81 patients had a low 4T score 0-3. Analysis of testing trends showed 60.44 % of patients were tested for HITAb despite being low risk using the 4T model. Only three patients with low 4T score were positive on confirmatory SRA testing (NPV 96.29 % CI 95 = 89.56-99.23 %). Expenditure due to inappropriate testing and treatment was estimated at $103,348.13. The majority of HITAb testing was found unnecessary based on the investigator calculated 4T score. We propose implementation of an electronic medical record (EMR) based calculator in order to reduce unneeded tests and reduce use of costlier alternative anticoagulants.

Cancer survivorship in hematologic malignancies: Lifestyle changes after diagnosis.

BACKGROUND: Studies show that patients make lifestyle changes soon after certain solid tumor diagnoses, suggesting that this may be a teachable moment to motivate and promote healthy behaviors. There is a paucity of data regarding changes made after a diagnosis of a hematologic malignancy. METHODS: A cross-sectional study of 116 patients at a community oncology center who completed anonymous questionnaires was performed. Questions addressed lifestyle choices made with respect to smoking, alcohol consumption, recreational drug use, diet, and exercise habits before and after diagnosis of a hematologic malignancy. Support systems utilized, including psychiatry services, were also assessed. RESULTS: Patients exhibited significant reduction in smoking behavior (Χ2  = 31.0, p < 0.001). 82.4% (n = 14) of one pack per day smokers quit between the time periods, with nearly all smokers showing a reduction after diagnosis. Alcohol use overall did not change significantly, however, 10.3% (n = 12) of patients reported quitting drinking completely between time periods. Changes in dietary intake and exercise were not statistically significant overall. Utilization of external support systems correlated with improved diet as well as decrease in total smoking years. CONCLUSIONS: This study demonstrates that patients exhibited significant lifestyle changes after being diagnosed with a hematologic malignancy. Clinicians should take advantage of this 'teachable moment' to educate patients about positive health behavior changes. Advances in cancer therapeutics have led to an increase in cancer survivors, this education is crucial in reducing the risk of developing chronic comorbidities as well as secondary malignancies.

Deep Brain Stimulation Surgery for Essential Tremor in a Patient with Type A Hemophilia.

BACKGROUND: Hemophilia is generally considered a contraindication to deep brain stimulation (DBS) and other elective intracranial surgery because of the elevated risk of perioperative hemorrhage. Two prior case reports have suggested, however, that DBS may be safe in patients with hemophilia who undergo appropriate factor replacement. Here, we describe a third case of DBS surgery for medically refractory essential tremor (ET) in a patient with hemophilia A. CASE DESCRIPTION: A 68-year-old right-handed man with mild hemophilia A presented for a 10-year history of bilateral (right greater than left), medically refractory ET. The patient was considered an appropriate candidate for DBS by a multidisciplinary movement disorders conference, and hematology consultation was obtained. Baseline preoperative laboratory results showed a quantitative factor VIII (FVIII) level of 38%. Perioperative management consisted of daily intravenous bolus doses of recombinant FVIII from the morning of surgery to postoperative day 10. The patient underwent uncomplicated unilateral DBS placement in the left ventralis intermedius thalamus. Intra- and postoperative imaging showed no hemorrhage. His postoperative course was uncomplicated except for a single self-limited episode of hematuria requiring no intervention. CONCLUSIONS: DBS placement for ET may be safe in patients with coexisting hemophilia A if appropriate FVIII replacement is given, which may be delivered as bolus infusions rather than continuous infusion.