Citations

SummaryVenous thromboembolism (VTE) has an increased incidence in patients with multiple myeloma (MM), especially during chemotherapy. Mechanisms including upregulation of procoagulant factors, such as factor VIII, have been postulated. The National Cancer Institute of Canada Clinical Trials Group MY.10 phase III clinical trial compared thalidomide‐prednisone to observation for 332 patients with MM post‐autologous stem cell transplantation (ASCT), with a primary endpoint of overall survival and various secondary endpoints including the incidence of VTE. One hundred and fifty‐three patients had biomarker data, including D‐dimer, factor VIII and thrombin anti‐thrombin (TAT) levels collected post‐ASCT at baseline and 2 months after intervention investigating in‐vivo thrombin generation. Differences between the time‐points included a significant reduction over time in D‐dimer, factor VIII and TAT levels in the observation group and sustained elevation of D‐dimer, significant increase in factor VIII and reduction in TAT levels in the thalidomide‐prednisone group. Eight VTE events were reported in this subset of study patients, all in the thalidomide‐prednisone arm, with a trend to increase in D‐dimer levels over time in those patients with VTE. This study provides physiological and clinical evidence for an increased risk of VTE associated with thalidomide‐prednisone maintenance therapy post‐ASCT for MM.

SummaryWe constructed a multiple myeloma (MM)‐specific gene panel for targeted sequencing and investigated 72 untreated high‐risk (del17p) MM patients. Mutations were identified in 78% of the patients. While the majority of studied genes were mutated at similar frequency to published literature, the prevalence of TP53 mutation was increased (28%) and no mutations were found in FAM46C. This study provides a comprehensive insight into the mutational landscape of del17p high‐risk MM. Additionally, our work demonstrates the practical use of a customized sequencing panel, as an easy, cheap and fast approach to characterize the mutational profile of MM.

Background and Purpose— Clinical equipoise of carotid revascularization therapies remains controversial. We sought to determine whether adverse outcomes after carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS) were similar using propensity score–matched analysis of retrospective data from a large hospital discharge database. Methods— All CEA and CAS cases were identified from the 2006 to 2011 Premier Perspective Database and subjected to 1:1 propensity score matching using 33 clinical covariates associated with carotid revascularization. A primary composite end point of peri- or postoperative mortality, stroke, or acute myocardial infarction and a modified composite end point excluding acute myocardial infarction were used to compare our findings with recent prospective controlled trials. Multivariate regression and Cox-proportional hazard ratio survival analysis were performed to compare revascularization therapy outcomes. Results— After 1:1 propensity score matching, 24 004 (12 002 CEA and CAS) asymptomatic and 3506 (1753 CEA and CAS) symptomatic procedures were included. The risk of the primary composite end point was significantly higher after CAS than CEA in both asymptomatic (odds ratio, 1.40 [1.19–1.65]; P <0.0001) and symptomatic (odds ratio=2.31 [1.78–3.00]; P <0.0001) presentations, irrespective of age ( P =0.28) or sex ( P =0.35). Similar findings were observed using the modified composite end point for both asymptomatic (odds ratio, 1.49 [1.25–1.78]; P <0.0001) and symptomatic (odds ratio, 3.02 [2.25–4.07]; P <0.0001) presentations. Acute myocardial infarction risk was not significantly different between revascularization therapies, regardless of clinical presentation ( P =0.71 and 0.24). Conclusions— Among individuals undergoing carotid artery revascularization from a large sample of US hospitals, CAS was associated with higher risk of perioperative mortality, stroke, and unfavorable discharges compared with CEA for all ages and clinical presentations.

Venous thrombosis is a common medical problem. Imaging differentiation of neoplasms and venous clots may prove challenging. We report three cases of “mistaken identities” of venous thrombi and neoplasms on the basis of clinical findings and different imaging modalities: ultrasound, computed tomography, and magnetic resonance imaging. Imaging studies are not always reliable and consideration of clinical features, including pretest probability, is necessary for correct diagnosis. A combination of imaging modalities and biopsies is needed for correct diagnosis in some cases.

Background: Telemedicine is used for specialist consultation, patient evaluation, and remote monitoring. We propose that telemedicine has a valuable role in medical education through facilitating faculty supervision of trainees. Materials and Methods: We surveyed resident physician trainees and faculty at a single institution who provided service for acute neurologic consultations over 29 months. The survey compared experiences using the supervisory methods of telephone, robotic telepresence (RTP), and in-person interaction. Participants answered 10 questions addressing their experience relevant to faculty–trainee interaction quality and clinical supervision, achieved with the three supervisory methods under study. Results: Surveys were received from 20 of 36 trainees (56%) and 8 of 10 faculty members (80%). More than 90% of trainees and faculty strongly agreed that in-person communication was satisfactory for patient data review, problem synthesis, and refinement of the trainees' impressions, with RTP ranking a close second. Moreover, 38% of faculty and 70% of trainees reported the telephone method as unsatisfactory for reacquisition of patient history, data synthesis, and direct observation of trainees' clinical skills. RTP provided more than 90% of trainees with sufficient staff support and facilitated trainee autonomy. Conclusions: Overall, 85% of both trainees and faculty preferred in-person supervision most, with RTP ranked second and telephone being least favored. Although in-person faculty supervision of trainees' management of neurologic emergencies is always preferred, it is not always practical. This survey highlights the valuable role of RTP in graduate medical education and RTP as preferred over telephone as an adjunctive supervision tool in residency.