IntroductionThe Choosing Wisely guidelines advise against ordering routine blood tests for hospitalised patients unless they change management. Unnecessary testing can lead to adverse effects (eg, iatrogenic anaemia, poor sleep quality, risk for infections and increased cost of care).MethodsAn 8-week quality initiative aimed at reducing unnecessary blood tests was implemented in three internal medicine resident inpatient services. The initiative included a 30 min educational session, reminders prior to rotation and midrotation and posters in work areas that displayed lab pricing and urged judicious testing. Residents were encouraged to justify the purpose of ordering tests in their daily progress notes. Attending physicians were made aware of the initiative. Preintervention and postintervention time points were used to compare key metrics. A >10% decrease between time periods was used as an evaluation criterion.ResultsThere were 293 patient records reviewed in the preintervention period and 419 in the postintervention period. The two groups were similar in terms of age and gender. Median blood test count (complete blood count/basic metabolic profile/comprehensive metabolic profile) decreased from 4 to 2 tests per patient per day (50 % decrease) after the intervention. The median length of hospital stay decreased from 4.9 to 3.9 days (21% decrease). A decreased percentage of people requiring transfusions was also noted (2016: 6.1%, 2017: 2.9%).ConclusionThe frequency of unnecessary routine blood tests ordered in the hospital can be decreased by educating resident physicians, making them cost conscious and aware of the indications for ordering routine labs. Frequent reminders are needed to sustain the educational benefit.

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Background: Immune checkpoint inhibitors (ICI) are a new class of immunotherapy agents that empower the innate immune system to destroy cancer cells by overcoming checkpoints against autoimmunity and self-tolerance. ICI use against certain cancers has yielded impressive results. Pembrolizumab, an ICI approved by the FDA in 2014 for treatment of metastatic melanoma, is a monoclonal antibody which binds the programmed cell death protein 1 (PD1) receptor, blocking it’s activation. Recent case reports have demonstrated a link between pembrolizumab and severe immunotherapy related adverse events including the incidence of autoimmune disorders. Clinical Case: A 68-year-old male with hypertension and a past medical history of cutaneous melanoma treated fifteen years earlier with tumor resection was started on pembrolizumab after identification of new metastases to the lung and bones. After 3 cycles of therapy he began to experience dizziness, lightheadedness, and vision changes with diarrhea. Outpatient labs demonstrated hyperkalemia with hyponatremia. He was directed to the emergency department by his oncologist for presumed adrenal insufficiency, where he received one dose of IV dexamethasone (4 mg). Repeat labs demonstrated severe diabetic ketoacidosis with elevated blood glucose 981 (70-99 mg/dL), pH 7.19 (7.32-7.42), anion gap of 37 (4-15 mmol/L), and betahydroxybutyrate > 9.00 (0.00-0.40 mmol/L). Following endocrinology consultation steroids were discontinued in favor of iv insulin and fluid resuscitation, with admission to the medical intensive care unit. Further lab testing demonstrated low C-peptide levels and positive IA-2 and GAD-65 antibodies, confirming autoimmune diabetes. Endoscopic biopsy was also consistent with autoimmune colitis, and TSH one month after discharge was 123.70 (0.30-5.00 mcIU/mL) with free T4 < 0.1 (0.6-1.6 ng/dL). Despite early discontinuation of anti-PD1 therapy the melanoma has remained in remission for three years, suggesting a sustained immune response. He continues to require insulin and thyroid hormone replacement, though the autoimmune colitis has resolved. Conclusion: This case demonstrates the overall benefit of immune checkpoint inhibitor therapy in the treatment of metastatic melanoma, while highlighting a potentially lethal therapy complication with the concurrent onset of multiple autoimmune processes affecting separate organ systems. Increased awareness of the potential for DKA in patients not previously diagnosed with diabetes is needed to avoid delays in care and improve outcomes. This case also suggests a potential benefit to integrating routine blood glucose monitoring in immune checkpoint inhibitor treatment protocols, the utility of which should be further investigated.

Background: Stem cell transplantation is a potential curative procedure for many patients with hematologic malignancies. These patients because of age, comorbid medical conditions, and prior therapies can present in various physical conditions from good performance status to frail, which may affect transplant outcomes. Objective: To assess the relationship of measurable physical conditioning metrics to survival, progression-free survival, relapse rate, and transplant-related morbidity and mortality in the context of our current rehabilitation program. Methods: We conducted a retrospective review of 207 patients who had undergone hematopoietic stem cell transplantation with 6 months of follow-up. Data were collected from their pretransplant rehabilitation evaluation and their 60-day posttransplant evaluation including their Karnofsky Performance Status (KPS) score, Timed Up and Go, pain, fatigue, and distress measurements. Using their KPS score patients were categorized as high performers (KPS ≥80) and low performers (KPS ≤70). Results: Patients experienced significant decreases in pain, fatigue, and distress after transplant. There were no significant differences in overall survival, progression-free survival, relapse rate, or transplant-related mortality between high and low performers. When controlling for transplant type, high performers had half the risk of dying compared with low performers. Conclusions: Our study demonstrated better posttransplant standard measures regardless of initial performance status. Our data suggest that patients with a better pretransplant performance status have better overall survival. One limitation of our study is the exercise program was not supervised and adherence is unknown.