Prothrombin Time and Activated Partial Thromboplastin Time Testing: A Comparative Effectiveness Study in a Million-Patient Sample.

BACKGROUND: A substantial fraction of all American healthcare expenditures are potentially wasted, and practices that are not evidence-based could contribute to such waste. We sought to characterize whether Prothrombin Time (PT) and activated Partial Thromboplastin Time (aPTT) tests of preoperative patients are used in a way unsupported by evidence and potentially wasteful. METHODS AND FINDINGS: We evaluated prospectively-collected patient data from 19 major teaching hospitals and 8 hospital-affiliated surgical centers in 7 states (Delaware, Florida, Maryland, Massachusetts, New Jersey, New York, Pennsylvania) and the District of Columbia. A total of 1,053,472 consecutive patients represented every patient admitted for elective surgery from 2009 to 2012 at all 27 settings. A subset of 682,049 patients (64.7%) had one or both tests done and history and physical (H&P) records available for analysis. Unnecessary tests for bleeding risk were defined as: PT tests done on patients with no history of abnormal bleeding, warfarin therapy, vitamin K-dependent clotting factor deficiency, or liver disease; or aPTT tests done on patients with no history of heparin treatment, hemophilia, lupus anticoagulant antibodies, or von Willebrand disease. We assessed the proportion of patients who received PT or aPTT tests who lacked evidence-based reasons for testing. CONCLUSIONS: This study sought to bring the availability of big data together with applied comparative effectiveness research. Among preoperative patients, 26.2% received PT tests, and 94.3% of tests were unnecessary, given the absence of findings on H&P. Similarly, 23.3% of preoperative patients received aPTT tests, of which 99.9% were unnecessary. Among patients with no H&P findings suggestive of bleeding risk, 6.6% of PT tests and 7.1% of aPTT tests were either a false positive or a true positive (i.e. indicative of a previously-undiagnosed potential bleeding risk). Both PT and aPTT, designed as diagnostic tests, are apparently used as screening tests. Use of unnecessary screening tests raises concerns for the costs of such testing and the consequences of false positive results.

Long-term disease control of refractory anaplastic large cell lymphoma with vinblastine.

Anaplastic large cell lymphoma (ALCL) is a unique clinical and pathologic subtype of lymphoma characterized by the proliferation of large, highly pleomorphic CD30-positive cells. Overall 70% to 80% of children with ALCL are cured with modern chemotherapy regimens, but the disease is often resistant to multiple therapies after relapse. Single agent vinblastine therapy has been effective in some cases of refractory ALCL. We report a case of ALCL originally diagnosed in an 8-year-old girl. After relapse, the disease was refractory to multiagent chemotherapy, but has showed remarkable response to, and dependence on, single agent vinblastine treatment for almost 7 years.

Transplacental transmission of metastatic melanoma to the posterior fossa. Case report.

The authors describe the first documented case of transplacental transmission of metastatic melanoma to the neuraxis. The patient was a 7-month-old boy who presented with signs and symptoms of elevated intracranial pressure. Magnetic resonance imaging revealed an inhomogeneously enhancing posterior fossa mass measuring 5 x 5 x 6 cm and filling the fourth ventricle. A posterior fossa craniotomy was performed. Pathological studies confirmed the presence of a metastatic melanoma that was pathologically identical to that of his mother. The boy received aggressive chemotherapy and underwent an additional resection. He also required a ventriculoperitoneal shunt for treatment of his hydrocephalus. He lived longer than any other patient with transplacental transmission of metastatic melanoma but ultimately died of the disease, 18 months after his initial presentation.