Cardiovascular Effects of Androgen Deprivation Therapy in Prostate Cancer.

PURPOSE OF THE REVIEW: This review paper is a comprehensive look at the cardiovascular disease (CVD) risk that is associated with the use of androgen deprivation therapy in prostate cancer. It summarizes when certain cancer therapies are indicated and should guide physicians in identifying patients at increased risk for CVD during prostate cancer therapy. RECENT FINDINGS: GnRH agonist use and maximal androgen blockade (MAB) are associated with increased CVD. This association is not observed in patients on GnRH antagonists. One example is the novel agent abiraterone, which is associated with hypertension whose mechanisms are likely driven by mineralocorticoid excess. Incidence of cardiovascular disease events is greatest when using MAB, especially in patients with pre-existing CVD. There is significant confounding that exists given patients with more aggressive cancers tend to be older and have more co-existing CVD. Given the lower CVD event rates with GnRH antagonists, future studies and strategies should focus on high-risk cancer patients with co-existing CVD receiving antagonists over agonists.

Percutaneous Transthoracic Treatment of Ascending Aortic and Root Pseudoaneurysms: Procedural Aspects and Guidance with the Use of Multimodality Imaging.

Open repair of ascending aortic pseudoaneurysms (AAPs) is currently the standard of care, but it is associated with high morbidity and mortality. A single-center retrospective experience of 4 patients after cardiac surgery undergoing 5 percutaneous transthoracic embolization procedures is presented. In 3 of the 4 patients, the primary outcome of complete thrombosis was achieved after the first procedure, with a mean follow-up time of 11.5 months. In all 5 procedures, the patients tolerated the procedure well without associated acute complications. Percutaneous transthoracic embolization of AAPs offers an alternate minimally invasive treatment pathway for prohibitive-risk candidates.

M#1045: Training Course in Focused Assessment with Sonography for HIV/TB in HIV Prevalent Medical Centers in Malawi.

PURPOSE: Training medical providers of different backgrounds the "focused assessment with sonography for HIV-associated TB" (FASH) exam to expand the availability of ultrasound for TB diagnosis in resource poor settings in the central region of Malawi. METHODS AND MATERIALS: A survey was completed by the 19 eligible participants before and after a 4-day training course regarding the utility of the FASH exam. A six-question quiz was used to assess knowledge of the use of ultrasound in the FASH exam before and after the course. RESULTS: Participants' knowledge of the FASH technique significantly improved after the four-day course with a 32% increase in total quiz questions answered correctly (p<0.001).Ninety-five percent (n= 18) of participants answered that they would "likely" incorporate FASH in their clinical practice. Furthermore, 100% (n=19) of participants agreed that the FASH exam would improve their ability to diagnose TB and 95% (n=18) agreed that FASH would improve patient care in their clinic. CONCLUSIONS: After completing a 4-day training course, medical providers were more knowledgeable about the FASH exam and its findings, and felt more comfortable using ultrasound for the diagnosis of TB. Participants were also unanimous in opinion that the FASH ultrasound exam would improve their ability to diagnose TB.

Pooled analysis of the CONFIRM registries: impact of gender on procedure and angiographic outcomes in patients undergoing orbital atherectomy for peripheral artery disease.

PURPOSE: To compare the acute procedure and angiographic outcomes of peripheral artery disease (PAD) patients treated with orbital atherectomy stratified by gender. METHODS: The CONFIRM I, II, and III registries are US multicenter, nonrandomized, all-comers registries of PAD patients who were treated with orbital atherectomy. All patients with gender specified in the registry database were included in the current analysis, which compared the final residual stenosis achieved after atherectomy and the rate of acute complications in female and male patients. The 3 registries included 3131 patients with 4761 lesions: 1261 women (mean age 73.2 ± 10.7 years) with 1874 lesions and 1870 men (mean age 70.4 ± 10.2) with 2887 lesions. RESULTS: The women were older (p < 0.001) and had a higher but nonsignificant prevalence of critical limb ischemia (p = 0.075). After treatment, the final residual stenosis in women vs. men was 9% ± 11% vs. 11% ± 11%, respectively (p < 0.001). Women had a higher rate of all types of dissection (13.3% vs. 9.9%, p<0.001). However, both genders had similar rates of flow-limiting dissections (1.6% vs. 1.4%, p = 0.61), perforation, slow flow, vessel closure, spasm, embolism, and thrombus formation. CONCLUSION: The gender analysis of the CONFIRM registries revealed that there was successful lesion modification with orbital atherectomy in both men and women; however, women had a higher rate of dissection (all types). This difference is likely because of the older age and higher percentage of critical limb ischemia in women in this cohort. These results, however, suggest that additional studies should be completed to further understand the increased risks for women vs. men during endovascular procedures.

A new approach to learning how to teach: medical students as instructional designers.

As students at the David Geffen School of Medicine at UCLA, the student authors were given the opportunity to develop their own creative projects which would be used to teach future medical students. They chose their own topics, planned and researched their projects, and then implemented the projects in interactive digital Adobe Flash files. In the first project they created interactive case-based radiology teaching files. In the second project they integrated photographic images into the existing illustrative anatomy files. Students in subsequent years have learned from these files on computers both at home and in the school's anatomy lab. The experience of creating the files served as an opportunity for hands-on learning for the student authors, both of the material and of the practice of teaching. In this paper they describe why they undertook these projects, what exactly they did, and the impact their creation had on them. The projects demonstrate that student-driven educational materials are both possible and beneficial. Furthermore, their experience has allowed them to conclude that faculty at other medical schools should consider providing students with opportunities to develop their own creative projects that contribute to the curriculum.

Drug-eluting stent fracture: incidence, contributing factors, and clinical implications.

Stent fracture has been observed in noncoronary vessels, especially in the superficial femoral and popliteal arteries and with bare metal stents in saphenous vein grafts of coronary arteries. Since the introduction of drug-eluting stents, stent fractures have also been reported in small studies and case reports. We reviewed these publications to assess what is known regarding the incidence, contributing factors, and clinical implications of drug-eluting stent fracture in coronary arteries. The reported rate of drug-eluting stent fracture in coronary arteries ranges from 1 to 8%, although much of the available literature is derived from single-center studies that are heterogeneous in their study methods. A higher risk of stent fracture may be associated with the right coronary artery location, excessive tortuosity or angulation of the vessel, overlapping stents, and longer stents. The closed-cell design of the Cypher stent has been associated with increased rigidity that may increase the risk of stent fracture, although these studies did not assess the overall outcomes between the Cypher and Taxus stents in a head-to-head comparison. Stent fracture has been shown by most studies to be associated with a statistically increased incidence of focal in-stent restenosis, and some have shown an increased risk of target lesion revascularization. Other complications observed with stent fracture include stent thrombosis, coronary aneurysms, myocardial infarction, and sudden death.

Causes of death in patients undergoing percutaneous coronary intervention with drug-eluting stents in a real-world setting.

BACKGROUND: Reports of stent thrombosis and death in patients who have received drug-eluting stents (DES) have provoked debate regarding their long-term safety. We investigated the specific causes of death in patients receiving DES at an academic tertiary-care center. METHODS: A retrospective analysis of 1,023 consecutive patients who underwent percutaneous coronary intervention (PCI) with DES from 2003 to 2006 at UCLA Medical Center was performed. Dates and cause of death were obtained by reviewing the patient's medical record, contacting the patient's doctor, or accessing the Social Security Death Index and obtaining copies of death certificates at the Los Angeles County Registrar-Recorder/County Clerk office. If the cause of death could not be determined, it was reported "unknown." RESULTS: At a mean follow up of 2.9 +/- 1.3 years, 96 patients who underwent PCI with DES died during the analysis (9.4% mortality). The mean duration between index PCI and death was 331 +/- 324 days. The cause of death was unknown in 9 patients, thus the analysis was based upon 87 patients. There were similar number of cardiac (n = 44) and non-cardiac deaths (n = 43). The risk of PCI-related death was 1.3% (13/1023), which included 11 patients (1.1%) who died from stent thrombosis. Fourteen patients (1.4%) who presented with myocardial infarction (MI) and underwent PCI died, and 14 patients (1.4%) died from heart failure. Non-cardiac deaths included cancer, infection, respiratory failure and a cerebrovascular event. Age, chronic renal insufficiency, presentation with MI, chronic obstructive pulmonary disease, history of cerebrovascular event, orthotopic heart transplantation and left ventricular ejection fraction were significantly associated with increased mortality. CONCLUSIONS: Cardiac and non-cardiac causes of death contributed similarly to mortality in patients who underwent PCI with DES at a large tertiary care center that manages high-risk patients. Overall PCI-related death and stent thrombosis causing death were low. The majority of deaths occurred in patients after hospital discharge. The majority of patients who died in the hospital presented with acute MI and were in critical condition on presentation.