ABSTRACT
Current literature does not support routine testing for hereditary and acquired thrombophilia disorders in the inpatient setting. Testing in the acute setting rarely changes patient management or could lead to patient mismanagement. Despite prior educational interventions, continued overuse of inpatient testing warrants further quality improvement measures. A hard-stop best practice advisory pop-up was implemented in the electronic medical record in a multicenter academic hospital system to provide clinicians guidance on the appropriate use of thrombophilia testing at the point of care. Pre- and postintervention retrospective data were collected to assess clinical features before and after implementation. Before the intervention, 271 patients underwent inpatient hypercoagulability testing; after the intervention, 238 patients underwent inpatient hypercoagulability testing. The total number of labs ordered per patient decreased from 1185 to 910, a 13% reduction (P = 0.003). Overall, there was a savings of $23,597 in total direct cost and $123,153 in total charges when comparing the 6-month timeframes before and after the intervention (P < 0.01). Although this study found only mild reductions in thrombophilia testing, it presents a new means of providing point-of-care intervention and education for hypercoagulability testing in the inpatient setting.
ABSTRACT
Inflammatory myofibroblastic tumors (IMTs) are known to be associated with anaplastic lymphoma kinase (ALK) gene rearrangements. Other molecular alterations such as ROS proto-oncogene 1, receptor tyrosine kinase (ROS1), neurotrophic tyrosine receptor kinase (NTRK), and platelet-derived growth factor receptor (PDGFR) have also been identified in IMTs. Although there are no randomized controlled clinical trials comparing chemotherapy, tyrosine kinase inhibitors (TKIs), or other systemic therapies, the literature demonstrates the use of ALK-targeted TKIs as an effective strategy for the treatment of locally advanced or metastatic ALK-rearranged IMTs. This case report describes a patient with an ALK-rearranged locally advanced pulmonary IMT who was treated with neoadjuvant-intent crizotinib. The patient had a very favorable response to therapy, and surgery was declined. It is difficult to determine the duration and sequencing of TKI use in these settings as there is little published data to guide decisions. This report also includes a comprehensive compilation of published IMT cases with molecular alterations treated with systemic therapy, which also highlighted the duration of therapies and clinical outcomes.
ABSTRACT
Pembrolizumab (Keytruda), an anti-PD-1 antibody used in the treatment of several different malignancies has been identified to cause adverse effects pertaining to multiple body systems which include respiratory, gastrointestinal, dermatologic, and endocrine manifestations known as immune-related adverse events (IRAEs). Skin manifestations have been most described in current literature highlighting the most common adverse effects of this agent. However, adverse outcomes involving the oral mucosa have been rarely identified in the PD-1 and PD-L1 inhibitor classes of immunotherapeutic agents. We present a case of a 71-year-old male who was treated with a chemotherapeutic regimen including pembrolizumab for newly diagnosed squamous cell carcinoma of the lung, who later developed ulcerations on his tongue that were consistent with glossitis. Upon determining that this adverse effect may be immune-related, the patient was treated with oral prednisone 40 mg with a 10 mg taper each subsequent week, which resulted in significant improvement in the patient's symptoms following one month of treatment.
