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Background: Palliative care can enhance quality of life during a terminal hospitalization. Despite advances in diagnostic and treatment tools, blood cancers lag behind solid malignancies in palliative use. It is not clear what factors affect palliative care use in blood cancer. Methods: We used the 2016 to 2019 National Inpatient Sample to identify demographic and socioeconomic factors associated with receiving palliative care among patients over age 18 with any malignant hematological diagnosis during a terminal hospitalization lasting at least 3 days, excluding those receiving a stem cell transplant. Results: Palliative care use was documented 54% of the time among 49,720 weighted cases (9944 distinct individual hospitalizations), approximately evenly distributed across the years 2016-2019. Palliative care use was lowest in 2016 (51%) and highest in 2018 (58%), and increased with age, reaching 58% for those 80 years and older. Men and women were similarly likely to receive care. Patients of Hispanic ethnicity and African Americans received less palliative care (47% and 49%, respectively), as did those insured by Medicaid (48%), and those admitted to small or rural hospitals (52% and 47%, respectively). Charges for hospitalizations with palliative care were 19% lower than for those without it. Conclusions: This study highlights disparities in palliative care use among blood-cancer patients who died in the hospital. It seems likely that many of the 46% who did not receive palliative care could have benefitted from it. Interventions are likely needed to achieve equitable access to ideal levels of palliative care services in late-stage blood cancer.
RESUMEN
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious adverse effect of heparin, which can lead to a prothrombotic state. Prompt cessation of heparin and initiation of non-heparin anticoagulation is the standard of care for HIT. Nevertheless, the treatment can pose challenges, particularly in refractory HIT, in patients with contraindications to anticoagulation, or those requiring urgent surgery. Additionally, in rare cases, conventional anticoagulation therapy is not effective, necessitating alternative treatments such as plasma exchange (PLEX) and intravenous immunoglobulin (IVIG). CASE REPORT Here, we report the case of a 57-year-old male patient who developed mild acute cellular rejection, refractory HIT, and disseminated intravascular coagulation after liver transplant surgery. Heparin was stopped and argatroban was initiated for thromboembolism treatment, but hepatic artery thrombosis occurred in the setting of refractory HIT and caused transplant failure. The patient underwent a second liver transplant 1 month after the first surgery. He had 2 sessions of PLEX and received 1 dose of IVIG before and 1 dose during the operation. Despite advanced treatment with PLEX and IVIG, the refractory HIT persisted. Hepatic artery thrombosis recurred within 2 weeks and the transplant failed again despite catheter-directed intra-arterial thrombolysis and argatroban therapy. CONCLUSIONS Recently perioperative PLEX and IVIG have been used a few times for the treatment of refractory HIT. This is the first reported case of a liver transplant recipient with refractory HIT who underwent this treatment strategy. Further investigation is required to determine the efficacy and safety of preoperative and intraoperative administration of PLEX and IVIG, especially in liver transplant recipients with HIT.