Enforcing the "4T": An In-Line Calculator for HIT Antibody Ordering in the Electronic Medical Record.

Heparin-induced thrombocytopenia (HIT) remains a difficult clinical diagnosis, even with the under-utilized standardized scoring systems, like the '4T' score, to aid in clinical decision-making. Our quality improvement study sought to assess the use of '4T' score, improve the use of HIT antibody (HITA) testing and improvement management of possible HIT by implementing an in-line calculator with guidance within our electronic medical record (EMR) at our institution. We retrospectively reviewed patient charts between October 2017 and October 2018, assessing practices before and after implementation of the '4T' in-line calculator in April 2018. HITA were ordered inappropriately (for 4T <4) in 141 (67%) of 210 instances (75 before and 66 after). We found no statistically significant difference in positive predictive value (PPV) or 4T documentation in provider notes after its implementation. We were able to identify problematic areas in HIT management, such as the ordering of non-heparin anticoagulants, and implement additional changes addressing these problems.

Outcomes of upper tract urothelial carcinoma with isolated lymph node involvement following surgical resection: implications for multi-modal management.

BACKGROUND: There are limited data on the oncologic outcomes of upper tract urothelial carcinoma with isolated lymph node (LN) involvement (pN+ M0) following surgical resection. We examined pN+ M0 UTUC in a large, nationwide oncology dataset to characterize its natural history, describe trends in utilization of perioperative chemotherapy, and identify clinicopathologic features associated with survival. METHODS: We identified 794 patients aged 18-89 years who underwent radical nephroureterectomy with lymph node dissection for pN+ M0 UTUC from 2006 to 2013 in the National Cancer Database. The associations of clinicopathologic features with overall survival (OS) were evaluated using Cox regression models, and a simplified risk score was created. RESULTS: Median follow-up among survivors was 39.5 months, during which time 555 (70%) patients died. Over the study period, neoadjuvant chemotherapy utilization increased from 6.7 to 14.2% (p = 0.002), while adjuvant chemotherapy utilization remained stable (42.7 to 44.3%; p = 0.86). One-, 5-, and 8-year OS rates were 63.7%, 24.2%, and 18.7%, respectively. On multivariable analysis, older age, larger tumor size, higher pT stage, positive surgical margins, number of positive LNs, and non-receipt of adjuvant chemotherapy were independently associated with worse OS. A simplified risk score consisting of age, tumor size, pT stage, number of positive LNs, and margin status was created with predicted 5-year OS ranging from 12 to 44%. CONCLUSIONS: In this large, contemporary cohort, pN+ M0 UTUC was associated with a 5-year OS of only 24%. Clinicopathologic predictors of survival after surgical resection may improve risk-stratification, counseling, and selection of patients for multimodal management.

Cardiogenic shock from coronary vasculitis in granulomatosis with polyangiitis.

Granulomatosis with polyangiitis (GPA) is a systemic vasculitis characterised by necrotising inflammatory changes in small-sized and medium-sized vessels and granuloma formation. It most commonly involves the kidneys and respiratory tract, but it can present with widespread manifestations involving any organ system. Rarely, it causes coronary vasculitis which can precipitate a severe cardiomyopathy. Here, we report a patient who presented in cardiogenic shock requiring vasopressors and was found to have extensive myocardial ischaemia secondary to coronary vasculitis. Further investigation led to a diagnosis of GPA, and he responded to treatment with corticosteroids, cyclophosphamide and plasmapheresis.