Ultrasound is being introduced into many medical schools and incorporated into the anatomy curriculum; however, in most cases, this consists of proctored sessions which can be limited by faculty time and availability. Additionally, the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has significantly impacted medical education, especially ultrasound education, which has traditionally depended on hands-on practice and instruction. A structured, independent, hands-on learning curriculum using ultrasound would have many benefits. In this study, eight self-guided system-based modules were developed mirroring the undergraduate anatomy curriculum. For each scan, a beginner, intermediate, and advanced component was designed. Each module contains clear, stepwise directions for image acquisition, optimization, and interpretation of the anatomical structures and suggestions for troubleshooting. Students save ultrasound images as part of their digital portfolios for review with ultrasound faculty. This design provides an educational model to increase medical student opportunities for independent, structured, selfdirected anatomy learning with ultrasound that can be integrated with existing educational programs.
IntroductionThis study examined the role of echocardiographic and cardiac histomorphology parameters in predicting mortality in patients with cardiac AL amyloidosis.MethodsPatients with endomyocardial biopsy-proven cardiac AL amyloidosis treated at MD Anderson Cancer Center between 6/2011 and 6/2020 were identified. Stored echocardiographic images and endomyocardial biopsy samples were processed for myocardial strain analysis and a detailed histomorphology characterization.ResultsOf 43 patients; 44% were women and 63% white. Median age was 65 years; 51% underwent stem cell transplantation (SCT). Thirty patients (70%) died during follow up (median follow up: 4.1 years). Lower LA strain (<13.5%) and absence of SCT as a time-varying covariate were significantly associated with increased risk of death in the multivariate cox regression analysis. Higher LV mass and lower RV tricuspid annular plane systolic excursion were associated with increased odds of having ≥5% interstitial amyloid deposition on biopsy in the multivariate logistic regression analysis.ConclusionLower LA strain independently predicted mortality in our cohort, and its performance in the routine assessment of AL amyloidosis may be beneficial. Furthermore, SCT for cardiac AL amyloidosis was associated with improved OS. These findings need to be confirmed by larger studies in the era of contemporary systemic therapies.
Introduction:
Atrial fibrillation (AF) is common in cardiac amyloidosis and often symptomatic. Commonly used therapeutics may be poorly tolerated. Patients with cardiac AL amyloidosis carry a high risk of stroke and bleeding, making anticoagulation challenging. This study examined the incidence of AF, treatment patterns, and incidence of thrombotic or bleeding complications.
Methods:
Patients with endomyocardial biopsy-proven cardiac AL amyloidosis treated at a tertiary cancer center between 6/2011 and 6/2020 were identified. Demographic and clinical data were abstracted. Outcomes included the development of AF, stroke and bleeding. Severe bleeding was defined as intracranial bleeding, hemorrhagic pericardial tamponade, or bleeding requiring endoscopic investigation.
Results:
Out of 43 patients with cardiac AL amyloidosis, 51% were diagnosed with AF during the follow up period (median 4.2 years (95% CI, 2.8-8.6)). Of those, 41% were women and 73% were white. Median age was 65.5 years (61-70). No significant demographic differences were identified between patients with and without AF. Beta-blockers were initiated in 86% and continued for more than 3 months in 59% of patients. Amiodarone was initiated in 50% and continued for more than 3 months in 18%. Treatment with digoxin and diltiazem were less common (27% and 14%, respectively). Pulmonary vein isolation was performed in 14% of patients. Anticoagulation (AC) was used in 59% of patients with AF and 19% of patients without AF for a different indication. Bleeding was common; 23% of AF patients reported an episode of severe bleeding, 60% of whom were on AC, in comparison to 19% in patients without AF, 50% of whom were on AC. Stroke was diagnosed in 14% of patients with AF, 67% of whom received AC, compared to 14% of patients without AF, 33% of whom received AC.
Conclusions:
Although AF is common (51%) in patients with cardiac AL amyloidosis, treatment with rate or rhythm control strategies is challenging. Many patients do not tolerate treatment for more than 3 months. While a significant number did not receive AC, there was a substantial risk of severe bleeding (1/4) and stroke (1/7). Given improved survival with newer therapies for AL amyloidosis, a greater focus on improving management of AF and outcomes is needed.
Introduction:
Cardiac involvement occurs in ~50% of patients with light-chain (AL) amyloidosis and conveys a poor prognosis. This study examined the role of histopathologic and echocardiographic parameters in predicting mortality.
Methods:
Patients with endomyocardial biopsy-proven cardiac AL amyloidosis treated at MD Anderson Cancer Center between 6/2011 and 6/2020 were identified. Stored echocardiographic images were processed for longitudinal strain (global [GLS], apical, mid, basal) as well as radial and circumferential strain of the left ventricle (LV), right ventricle (RV) free wall, left atrium (LA), and right atrium, using the Epsilon EchoInsight Software. A detailed histomorphologic characterization of stored endomyocardial biopsy samples was performed by a cardiac pathologist and scored as < or > 5% AL deposits.
Results:
We identified 43 patients; 44% were women and 63% white. Median age was 65 years (IQR 59-70). Twenty-two (51%) underwent stem cell transplantation (SCT). A total of 29 patients (67%) died during follow up period (median follow up: 4.2 years (95% CI, 2.8-8.6)). Median overall survival (OS) was 18 months (95% CI, 8.1-37). Lower LA GLS and absence of SCT as a time-varying covariate were significantly and independently associated with increased risk of death in the multivariable cox regression analysis (HR 3.8, 95% CI 1.4-10.2 for LA GLS
<
13.5 vs >13.5, p=0.008 and 0.20, 0.06-0.65 for SCT vs no SCT, p<0.001, respectively). Higher LV mass and lower RV TAPSE were associated with increased odds of having >5% of interstitial amyloid deposition on biopsy in the multivariable logistic regression analysis (OR 5.5, 95% CI 1.1-26.8 for >195.6g vs ≤195.6g, p=0.036 and 8.1, 1.2-54.3 for RV TAPSE<1.6cm vs ≥1.6cm, p=0.032, respectively).
Conclusions:
LA GLS
<
13.5 was an independent predictor of mortality in our cohort, and its performance in the routine assessment of AL amyloidosis may be justified. Furthermore, SCT for cardiac AL amyloidosis was associated with improved OS. This finding needs to be confirmed by larger studies in the era of contemporary systemic therapies. Although LV mass and RV TAPSE were associated with higher interstitial amyloid deposition, histopathologic parameters did not predict mortality in this cohort.
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