Blasting the myth of predictive INR changes related to plasma transfusion: an academic institution's experience

Abstract Introduction Plasma transfusion is a common therapeutic strategy used to lower international normalized ratio (INR) values in the non-emergent setting. However, due to lack of evidence of its efficacy, standardized guidelines for this practice have not been well established. Methods This retrospective observational cohort study analyzed 276 inpatient encounters that involved plasma transfusions focusing on change in INR values from pre- to post-transfusion, with respect to the following predictor variables: vitamin K co-administration, number of plasma units transfused, order indication and body mass index (BMI). Results The overall average change in the INR was 1.35. Patients who received vitamin K showed an average change of 2.51, while patients that did not receive vitamin K demonstrated an average change of 0.70. Increased numbers of plasma units transfused showed benefit up to three-unit orders. Greater decreases in the INR were observed for patients requiring plasma for anticoagulation reversal or active bleeding. There was no significant difference in the change in INR based on the BMI. By multivariate and regression analyses, the stepwise addition of each successive predictor variable demonstrated an increase in the shared variance in the outcome of the post-transfusion INR: the pre-transfusion INR and vitamin K co-administration alone was not significant (p= 0.45); the additional number of plasma units transfused was significant (R² = 0.13, p < 0.001), and; the subsequent additional plasma order indications (R² = 0.19, p < 0.001) and BMI (R² = 0.18, p < 0.001) were increasingly significant. Conclusion Taking into consideration the combination of multiple predictive factors may aid in a more efficient use of plasma products.

Blasting the myth of predictive INR changes related to plasma transfusion: an academic institution's experience.

INTRODUCTION: Plasma transfusion is a common therapeutic strategy used to lower international normalized ratio (INR) values in the non-emergent setting. However, due to lack of evidence of its efficacy, standardized guidelines for this practice have not been well established. METHODS: This retrospective observational cohort study analyzed 276 inpatient encounters that involved plasma transfusions focusing on change in INR values from pre- to post-transfusion, with respect to the following predictor variables: vitamin K co-administration, number of plasma units transfused, order indication and body mass index (BMI). RESULTS: The overall average change in the INR was 1.35. Patients who received vitamin K showed an average change of 2.51, while patients that did not receive vitamin K demonstrated an average change of 0.70. Increased numbers of plasma units transfused showed benefit up to three-unit orders. Greater decreases in the INR were observed for patients requiring plasma for anticoagulation reversal or active bleeding. There was no significant difference in the change in INR based on the BMI. By multivariate and regression analyses, the stepwise addition of each successive predictor variable demonstrated an increase in the shared variance in the outcome of the post-transfusion INR: the pre-transfusion INR and vitamin K co-administration alone was not significant (p = 0.45); the additional number of plasma units transfused was significant (R²â€¯= 0.13, p < 0.001), and; the subsequent additional plasma order indications (R²â€¯= 0.19, p < 0.001) and BMI (R²â€¯= 0.18, p < 0.001) were increasingly significant. CONCLUSION: Taking into consideration the combination of multiple predictive factors may aid in a more efficient use of plasma products.

Cutaneous metastases of non-cutaneous neuroendocrine neoplasms: A histopathologic review of 15 cases.

BACKGROUND: Cutaneous metastases from non-cutaneous neuroendocrine neoplasms are rare; however, distinction from primary neuroendocrine carcinomas of the skin (Merkel cell carcinoma) guides clinical management. METHODS: We performed a retrospective review from September 1, 2010 to September 30, 2020 of the histopathologic, immunohistochemical, and clinical characteristics of metastatic neuroendocrine neoplasms to the skin from non-cutaneous primaries. RESULTS: Fourteen patients were identified for the study (nine males and five females; mean age of 59.5 years). Fifteen skin specimens from 14 patients were available for review. At the time of skin biopsy, a known non-cutaneous neuroendocrine neoplasm was present in 50% of patients. Primary sites of neuroendocrine carcinoma included lung (n = 5), terminal ileum (n = 2), and one each from prostate, breast, rectum, uterus, esophagus, and sinus, with one unknown (suspected bladder malignancy). Eleven of fourteen patients are dead of disease; one was lost to follow-up. All 15 specimens showed subcutaneous/deep dermal involvement with six involving the papillary dermis and one involving the epidermis. The tumors ranged from well to poorly differentiated. Two of fifteen specimens showed focal CK20 positivity (one metastatic uterine small cell carcinoma and one metastatic ileal carcinoid). TTF-1 was performed in 13 specimens and was positive in six, of which two were of non-pulmonary origin. CONCLUSIONS: While immunohistochemical stains, in particular CK20, CK7, and TTF-1, are integral in the workup of confirming the origin of neuroendocrine tumors found in the skin, results vary and are often non-specific for a single primary site. Therefore, complete radiologic imaging as well as clinical correlation should be recommended to further aid in the identification of a non-cutaneous primary neoplasm.

Improving ROSE: Discrepant touch preparation and histology findings in cytology of renal masses: A 10-year retrospective review.

BACKGROUND: The number of "renal incidentalomas" is on the rise due to increasing use of radiologic studies. Image-guided core needle biopsies (CNB) with touch preparations are performed to guide specimen collection and triage of sample for additional studies. Results allow the clinical team to make appropriate treatment decisions. DESIGN: Our electronic database was searched for a 10-year period to identify 180 image-guided biopsies of renal masses with rapid on-site evaluations (ROSE) and corresponding biopsy/resection specimens. Touch preparations were classified as non-diagnostic, negative/benign, adequate/positive for malignancy/oncocytic predominance, or atypical. These results were compared to the final diagnosis on the biopsy or resection specimen (if available). Diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values were determined. Non-diagnostic cases and cases in which ROSE and final diagnosis were discordant were reviewed by cytopathologists blinded to the original interpretation to reconcile discrepancies and highlight interpretation pitfalls. RESULTS: A ROSE diagnosis was rendered in 133 of 180 cases; 47 cases were non-diagnostic. Of the 133 diagnostic cases, the ROSE diagnosis was concordant with the core biopsy final diagnosis in 125 cases, yielding a diagnostic accuracy of 94%. The overall sensitivity was calculated to be 80.1%; specificity 72.4%; positive predictive value 94%; and negative predictive value 41.2%. CONCLUSIONS: Touch preparation slides are vital but imperfect tools in evaluating renal masses. In our study, distinction between malignant and benign samples was accomplished in most cases (94% accuracy), but there are limitations. Awareness of interpretation pitfalls allows informed decisions to be made regarding specimen collection and patient management.

Metastatic melanoma of the uterine cervix diagnosed on cervical Pap smear: Case report and literature review.

Metastatic cancer involving the uterine cervix is exceedingly rare, and accounts for less than 1% of cancer deaths. The cervix is an uncommon location for metastatic lesions due to its limited blood supply and fibrous stroma and metastatic melanoma of the cervix is particularly infrequent. To the best of our knowledge and literature review, there have only been nine reported cases in the literature of metastatic melanoma involving the uterine cervix that were diagnosed via cervicovaginal Pap smears, including the case being reported in this paper. Diagnosing metastatic melanoma on cervicovaginal cytology specimens is challenging, not only because of its rarity, but also because of the inherent ability of melanoma to take on many different cytomorphologic appearances. In such cases, the differential diagnosis may include a high-grade squamous intraepithelial lesion, atypical glandular cells, adenocarcinoma and other poorly differentiated malignancies. We report a case of malignant melanoma to the cervix diagnosed by a routine cervical Pap smear in a young woman who was diagnosed with cutaneous melanoma 3 years prior. Because of the diagnosis rendered on her cervical Pap smear, she was subsequently found to have widespread metastatic disease. Although the cervical Pap smear is primarily intended to screen for squamous intraepithelial lesions, a high index of suspicion must be maintained for other less common entities, particularly when there is no evidence of a squamous intraepithelial lesion.

Acute Hemolytic Transfusion Reaction in Group B Recipient Associated with Group A Apheresis Platelet Donor: Case Report and Literature Review.

Acute hemolytic transfusion reaction is a known but rare potential adverse event related to platelet transfusion. Most reported cases of platelet-related hemolytic transfusion reaction have resulted from transfusion of platelets from group O donor to group A recipient. We identified only one prior case report in the literature of hemolytic transfusion reactions resulting from transfusion of apheresis platelets from group A donor to group B recipient. In that case report, two platelet units were obtained from a single donation and transfused into two separate patients. Both patients exhibited acute hemolytic reactions. The donor is reported to have high anti-B titers, as well as report of probiotic use. We report a case of acute hemolytic reaction in group B recipient following transfusion of apheresis platelets from group A donor with high-titer anti-B but unknown status of probiotic use. This case demonstrates that while low, there still exists potential risk for hemolysis from out-of-group A plasma transfusion.