Purpose of review With the advancement of breast cancer therapies, most women diagnosed with breast cancer in the United States are now expected to survive their disease, and management of competing comorbidities, particularly cardiovascular disease (CVD), is crucial. Recent findings Recent studies have suggested that CVD is the most common cause of death for women diagnosed with ductal carcinoma in situ or stage I disease and for women aged more than 80 years with stage II disease. Various breast cancer therapies, including targeted therapies, can accentuate CVD risk; referrals for cardiology opinion are not uncommon at the time at which treatment options are under consideration. The use of less cardiotoxic alternatives, such as liposomal doxorubicin, and intensity-modulated radiation therapy should be considered when appropriate. Doppler myocardial imaging and cardiac MRI might allow early recognition of cardiotoxicity. Summary It is important to weigh both the risk of CVD and that of breast cancer recurrence in a breast cancer survivor. Certain interventions for the primary prevention of CVD, including diet, physical activity, smoking cessation and aspirin, can reduce breast cancer risk as well. The management of CVD risk factors is of increasing importance in the management of breast cancer survivors.
Introduction: Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease that is associated with recurrent pneumothorax, abdominal tumors including lymphangioleiomyomas and angiomyolipomas, chylous fluid accumulations and progressive respiratory failure. Sirolimus has been shown to slow the progression of disease.Areas covered: In this review, the current evidence, indications, precautions, and practical use of sirolimus therapy in patients with LAM is discussed.Expert opinion: In LAM, the lung becomes diffusely infiltrated with smooth muscle-like cells containing mechanistic target of rapamycin complex (mTOR) activating mutations in tuberous sclerosis genes which drive destructive parenchymal remodeling. LAM cells arise from an unknown source, migrate to the lung and express vascular endothelial growth factor D (VEGF-D). In the laboratory, mTOR inhibitors block destructive LAM cell behaviors including abnormal growth, migration and metalloproteinase production and induce tumor regression in animal models. The MILES trial demonstrated that sirolimus, stabilizes lung function, reduces VEGF-D and improves measures of functional performance. Based on MILES, sirolimus was approved by the United States Food and Drug Administration for the treatment of LAM in 2015. Available mTOR inhibitor therapies are suppressive, requiring chronic or even lifelong exposure for continued benefit. Multiple trials are underway to refine the use of mTOR inhibitors in LAM.
Study ObjectiveTo compare haemodynamic response in nasotracheal intubation under general anaesthesia between FOB and DLS as one accomplished with a FOB is thought to attenuate the circulatory responses to intubation as stimulation of the oropharyngeal structures may be avoided.DesignRandomized, prospective study.Patients50 ASA grade I and II patients of both sexes in the age group of 18–60 years scheduled for an elective surgery under general anesthesia.InterventionsPatients were randomly allocated to nasotracheal intubation facilitated with either the FOB [Group I] or the DLS [Group II]. A uniform protocol of anesthesia was used.MeasurementsHeart Rate [HR], Systolic Blood Pressure [SBP], Diastolic Blood Pressure [DBP] & Mean Arterial Pressure [MAP] in the two groups were compared at their baseline, post-induction values, at the time of insertion of the scope, immediately after intubation & at 3, 5 and 10 minutes after intubation.ResultsHaemodynamic response in the form tachycardia, increase in SBP, DBP & MAP occurred in nasotracheal intubations with both the fiberoptic bronchoscope and with direct laryngoscope. Tachycardia of similar magnitude was noted in both the groups following insertion of scope and after intubation whereas SBP, DBP & MAP were significantly high in Group II [p<0.01] at the time of intubation & SBP immediately after intubation was significantly high in Group I [p<0.05] Conclusions: Fiberoptic bronchoscopy provides no advantage over conventional laryngoscopy, in terms of decreasing the hemodynamic response to nasotracheal intubation under general anaesthesia.
Arrhythmias, especially supraventricular arrhythmias (SVA), often complicate autologous stem cell transplantation (ASCT). While easily treatable, they result in prolongation of hospital stay and increased rate of intensive care admissions. We undertook this study to determine the incidence and risk factors for cardiac arrhythmias during ASCT. We examined the medical records of 983 patients who underwent ASCT for various hematological malignancies between Aug 2006 and Dec 2010. The underlying disease included plasma cell disorders in 573 (58%) patients and lymphoma or leukemia in the remaining. The median age was 58 years (range; 19-77); 603 (61%) were male. Overall, 92 (9.4%) patients developed a SVA following ASCT, at a median of 9 days post transplant (range; 0, 18). Atrial fibrillation was most common and was seen in 71 (7%) patients, followed by atrial flutter, supraventricular tachycardia and multifocal tachycardia in 12 (1%), 8 (1%) and 1 (<1%) patients respectively. The rhythm had normalized in 81 (88%) patients at the time of dismissal post transplant, with a median duration of arrhythmia of <1 day (range; <1 to 17 days). We then examined various pre and peri-transplant clinical and laboratory parameters to identify risk factors for SVA. In a univariate analysis, older age, presence of supraventricular complexes or AV conduction delays on pre-transplant ECG, presence of any valvular abnormality, increased atrial size, any prior history of arrhythmia, or being on a beta blocker or an antiarrhythmic agent, all increased the risk. In a multivariate analysis, only age > 63 years, presence of supraventricular complexes or AV conduction delays on pre-transplant ECG, and history of any prior arrhythmia increased the risk of arrhythmia during transplant. Among the patients with age > 63 years, presence of supraventricular complexes or AV conduction delays on pre-transplant ECG, and history of any prior arrhythmia, 20%, 26% and 23% respectively developed an arrhythmia compared to 4%, 8% and 8% among those without the risk factors, respectively (P < 0.001 for all three comparisons). Among patients undergoing ASCT, 9% develop supraventricular arrhythmias. The risk is elevated among the older patients, those with a prior history of arrhythmias, and those with AV conduction delay or premature supraventricular complexes on ECG. Identification of patients at a higher risk may allow development of specific interventions.
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