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Introduction: Light chain multiple myeloma (LCMM) is a distinct subtype of multiple myeloma (MM) characterized by the exclusive production of immunoglobulin light chains, unlike the common form of MM that produces the complete immunoglobulin. There is a paucity of literature on the specific tumor cell alterations leading to light chain-only disease as opposed to the typical presentation in MM. Additionally, data on treatment response and outcomes in this subgroup of patients is sparse. This study explores the differences in baseline characteristics, including cytogenetic abnormalities and treatment response between LCMM and multiple myeloma with heavy chain involvement. Materials and Methods: We reviewed patient charts to obtain clinical and laboratory information for individuals diagnosed with LCMM and those with heavy chain MM (comparison cohort) from 2004 to 2022. Patients were matched for age, sex, and year of diagnosis. Data collected included treatment assessment, overall survival, and progression-free survival (PFS). Associations between outcomes and categorical variables were analyzed using the chi-square test, while the Mann-Whitney U test was employed to compare medians. Progression-free survival following initiation of initial therapy and overall survival were assessed using Kaplan-Meier analysis. The Mayo Clinic Institutional Review Board (IRB) approved the study. Results: We identified 848 patients, representing 17.1% of newly diagnosed MM cases. The median age of the LCMM cohort was 63 years (range 16-92), with a female-to-male ratio of 1:5. The LCMM cohort had higher levels of lactate dehydrogenase (LDH), beta-2 microglobulin (p<0.0001), higher baseline creatinine (p<0.0001) and calcium (p<0.0001). The two cohorts had no significant difference in the International Staging System (ISS) or revised ISS (R2-ISS). Additionally, hemoglobin (Hb) and white blood cell count at presentation were higher in the LCMM cohort. Chromosome 1 abnormalities were lower in the LCMM cohort: 1q gain (OR-0.7; 95% CI: 0.6-0.9) and 1p deletion (OR-0.7; 95% CI: 0.6-0.9, p=0.02). Likewise, the frequencies of trisomies and hyperdiploidy were lower in the LCMM cohort, with odds ratios of 0.32 (p=0.012) and 0.37 (p<0.001), respectively. The frequencies of translocations t(4;14) (OR-0.35, p<0.001) and t(14;16) (OR-0.6, p=0.03) were lower in LCMM compared to heavy chain MM. In contrast, the frequencies of t(11;14) (OR-3.4) and t(6;14) (OR-4.9) and deletion of 13q(OR-1.3) was higher in the LCMM cohort. There was no significant difference in the occurrence of del(17p)/TP53 abnormalities. The median PFS after the first regimen was shorter in the LCMM cohort (23 months vs. 27 months, p=0.03), and this difference remained significant after adjusting for baseline adverse prognostic indices and treatment regimen. Median PFS in LCMM patients with monoclonal antibody (Mab) as part of their treatment was 37 months vs. 23 months (Proteasome Inhibitor or immunomodulator-based regimen without Mab), though this difference is not statistically significant p=0.87. No significant difference was found in overall survival between the two groups. Conclusion: This study highlights unique features of light chain multiple myeloma, including increased frequencies of specific cytogenetic abnormalities. Further evaluation of observed differences in cytogenetic abnormalities may enhance our understanding of LCMM and potentially guide baseline treatment choices to improve outcome.

Background: Despite effective front-line therapies, DLBCL & MM have high relapse rates. Novel therapies like CAR-T & bispecific antibodies (BsAb) offer deep & durable remission compared to salvage therapies, but have a unique toxicity profile (TP) that requires monitoring. With no head-to-head trials, the rationale for therapy selection may vary. This study explores provider choices, sequencing preferences, & access barriers. Methods: Two anonymous surveys (MM and DLBCL) of US-based Hematologists were conducted from 2/2024 to 6/2024, on practice settings, CAR-T & BsAb availability, treatment preferences & barriers. Responses were analyzed to assess preferences across clinical scenarios. Results: Surveys were completed by 37 MM & 45 DLBCL providers. Most were at centers offering both CAR-T & BsAb. Most gave CAR-T inpatient, & BsAb outpatient. CAR-T was given by 73% MM providers & 66% DLBCL (92% used Cilta-cel, 96% used Ide-cel; 100% used Axi-cel, 90% used Liso-cel & 73% Tisa-cel). In MM, 78% used Teclistamab, 60% Talquetamab & 24% Elranatamab. In DLBCL, 62% used Epcoritamab & 40% Glofitamab. Providers preferred CAR-T over BsAb in MM after 4+ prior lines of therapy (LOT) (89%), & in DLBCL after 2+ prior LOT (93%). CAR-T was favored more among academic providers & those at CAR-T centers. Practice volume did not impact selection. Among providers at centers with BsAb-only, CAR-T was preferred by 60% (MM) and 50% (DLBCL). Providers at centers without both favored CAR-T (MM: 75%, DLBCL: 86%). CAR-T was chosen for better outcomes, short treatment, center choice, & prior experience. Other factors that influenced decisions were lower incidence of cytopenia/infection & “BsAb effective post-CAR-T, less so vice versa” (MM), & “curative potential of CAR-T” (DLBCL). Logistical barriers & institutional constraints influenced BsAb selection: CAR-T unavailability, access to specialized centers, referral complexity, insurance delay, manufacturing delay & hospitalization needs. In MM, 78% providers preferred Cilta-cel over Ide-cel, especially academic providers & those with CAR-T experience. CAR-T volume did not impact selection. Cilta-cel was preferred due to perceived better response rate (RR), more experience, “progression-free survival (PFS) benefit”, center choice, & logistical issues with Ide-cel. Ide-cel was selected due to center choice, favorable TP & insurance preference. Teclistamab was preferred by 78% due to more experience, better RR, TP & center choice, Elranatamab by 11% (better TP, RR, & “PFS”), & Talquetamab by 11% due to having a non-BCMA target. Academic providers preferred Teclistamab (89% vs 50%), & nonacademic providers preferred Talquetamab (38% vs 4%) and Elranatamab (13% vs 8%). In DLBCL after 2+ LOT, 69% favored Axi-cel due to prior experience, RR, center choice, & logistical issues with other products. Liso-cel & Tisa-cel were chosen by 27% & 2%, respectively, due to favorable TP. Axi-cel was also preferred 2nd line by 73% for similar reasons, while 24% favored Liso-cel for its favorable TP. Epcoritamab was preferred by 56% (subcutaneous injection, more experience & center choice) & Glofitamab by 42% (shorter treatment duration, easy administration, more experience, & center choice). Practice setting & volume did not impact selection between products in DLBCL. InBCMA-naïve MM pts, majority (97%) chose an anti-BCMA agent over GPRC5D due to better RR, TP, prior experience, & center choice. InBCMA-exposed pts, most (92%) favored an anti-GPRC5D agent. In contrast in DLBCL, 80% chose CD19 CAR-T after prior CD19-directed therapy, & 18% chose CD20 BsAb. Therefore, antigen escape was less of a concern in DLBCL vs MM. For relapse after 2nd line CAR-T in DLBCL, 78% preferred BsAb over other salvage options due to better RR, TP, & more experience. Providers prioritized RR, survival, & TP in decision making. Treatment logistics, duration, frequency, & cost were less crucial. MM providers also prioritized quality of life, which was less so in DLBCL. There were no differences in priority based on practice setting & experience with CAR-T. Conclusion: The study highlights factors influencing therapy choices in MM & DLBCL. Despite CAR-T's potential for better outcomes, significant access barriers exist. Efforts to streamline referral pathways, logistics, & expanding availability are crucial to improve outcomes. Understanding these preferences & barriers can guide future management strategies.

Abstract Patient-reported outcomes (PROs) are associated with treatment outcomes in multiple myeloma (MM) in the clinical trial setting. However, most PRO tools are time consuming, which hinders use in routine practice. Our institution incorporated a “Hematology Patient-Reported Symptom Screen” (HPRSS), a 3-item questionnaire for fatigue, pain, and quality of life (QOL). The main objective of this study was to evaluate the impact of these symptoms on progression-free survival (PFS) and overall survival (OS) in a real-world cohort of patients with newly diagnosed MM. This retrospective study included patients with MM diagnosed between April 2011 and December 2017, seen at Mayo Clinic (Rochester, MN), who completed the HPRSS. Patients rated their symptoms on a scale from 0 to 10. Clinically relevant symptoms were defined as scores ≥5 for pain and fatigue, and ≤5 for QOL. At diagnosis, 735 patients had scores for all domains. The median follow-up was 8.1 years. Age was associated with increased odds of fatigue and decreased QOL. Female sex and comorbidities were associated with fatigue and pain. Higher disease stage, anemia, lytic lesions, and increased plasma cell burden were associated with fatigue, pain, and decreased QOL. Clinically relevant fatigue, pain, and decreased QOL were associated with decreased PFS and OS. On multivariate analysis including age, International Staging System III, high-risk cytogenetics, and postinduction transplantation, fatigue and decreased QOL were independently associated with decreased OS. A composite HPRSS score stratified patients into 3 groups with distinct OS. Patient-reported symptoms are prognostic in patients with newly diagnosed MM. The prognostic values of fatigue and decreased QOL are independent of age, disease stage, and transplant status.

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) using venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a promising strategy for refractory cardiac arrest. However, the role of left ventricular (LV) unloading during ECPR remains uncertain. Methods: We queried the United States National Inpatient Sample (2016-2021) to identify adult patients with out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA) who received ECPR. Patients were stratified based on the use of either VA-ECMO only or VA-ECMO with intra-aortic balloon pump (IABP) or VA-ECMO with Impella (ECPELLA) for ventricular unloading. Multivariable logistic regression was used to compare in-hospital outcomes between the groups. Results: Among 6,915 patients receiving ECPR, VA-ECMO alone was used in 5,145 (74.4%), VA-ECMO-IABP in 809 (11.7%), and ECPELLA in 961 (13.9%). The LV unloading groups more frequently presented with ventricular tachycardia/fibrillation (61.1% and 72.4% vs. 43.9%, both p<0.01), while the VA-ECMO only group more often presented with pulseless electrical activity/asystole (56.1% vs. 38.9% and 27.6%, both p<0.01). In IHCA patients, ECPELLA was associated with 50% lower odds of in-hospital mortality compared to VA-ECMO alone (adjusted odds ratio [aOR] 0.50, 95% CI 0.31-0.81, p<0.01). No significant difference was found in OHCA patients. VA-ECMO-IABP was not associated with a mortality benefit vs. VA-ECMO alone in either OHCA or IHCA (Figure 1). Cardiovascular complications were significantly higher in both LV unloading groups compared to the VA-ECMO only group in OHCA subgroup (90% and 95% vs. 73.3%, both p<0.01) while IHCA subgroup only showed higher significant rates in ECPELLA compared to VA-ECMO alone (89.3% vs. 81%, p=0.04) (Figure 2). After adjustment for potential confounders, VA-ECMO-IABP (aOR 2.79, 95% CI 1.02-7.60, p=0.04) and ECPELLA (aOR 6.92, 95% CI 2.09-22.94, p<0.01) were associated with significantly higher odds of cardiovascular complications compared to VA-ECMO alone among OHCA patients, but not among IHCA patient. There were no statistically significant differences in neurologic, renal, and hematologic complications between the three groups in either OHCA or IHCA patients (Figure 3). Conclusion: In this nationwide study, LV unloading with ECPELLA was associated with improved survival in IHCA patients but not in OHCA patients compared to VA-ECMO alone. The addition of IABP to VA-ECMO was not associated with a mortality benefit.

Background: Pulsatile perfusion is a developing technique that attempts to mimic the natural pulsatile flow of blood during cardiopulmonary bypass (CBP). Purpose: Our meta-analysis was done to evaluate the effects of pulsatile perfusion in CPB compared to non-pulsatile on hospital stay, ICU stay, and intubation time. Methods: Randomized control trials that evaluated the implementation of pulsatile perfusion during CPB were identified by a literature search of the following databases (PubMed, Web of Science, Scopus, Central, and Embase) up to February 2024. Results: Our search yielded 33 trials with 3174 patients, the analysis showed that pulsatile perfusion led to a significant decrease in hospital stay [MD = -1.38, 95% CI (-2.51, -0.25), P = 0.016], ICU stay [MD = -0.47, 95% CI (-0.82, -0.13), P = 0.007], intubation time [MD = -3.73, 95% CI (-5.42, -2.04), P < 0.001]. However, no significant difference between the two regimens was detected in the adult subgroup when we performed sungroup analysis based on the age for hospital stay and ICU stay outcomes [MD = -0.31, 95% CI (-0.95, 0.33), P = 0.334] and [MD = -3.73, 95% CI (-5.42, -2.04), P < 0.001] respectively. Conclusion: Pulsatile perfusion showed positive effects on hospital stay, ICU stay, and intubation time. However, there was no difference between the two methods on hospital and ICU stay in the adult’s subgroup. Also, the outcomes showed significant heterogeneity, which requires more robust RCTs to be conducted to increase the quality and the certainty of evidence.

Older patients with multiple myeloma (MM) exhibit wide heterogeneity in their baseline physiologic and functional status, which demands an individualized treatment approach based on biological rather than chronological age. Various frailty scores have been developed for older patients with MM, but they are underutilized in clinical trials and in practice. Older patients with MM are underrepresented in therapeutic clinical trials, and treatment recommendations are currently derived from clinical trials of transplant-ineligible patients. This article provides a summary of phase II and III clinical trials in transplant-ineligible patients with newly diagnosed MM, highlighting outcomes in patients aged ≥75 years and frailty-based outcomes. The data available thus far show that triplet regimens are more efficacious than doublets in older patients but may be associated with higher toxicity. DRd (daratumumab/lenalidomide/dexamethasone) and VRd (bortezomib/lenalidomide/dexamethasone) are good options in patients who are nonfrail, whereas dose-adjusted DRd and VRd-lite should be offered to frail patients. Frailty should be assessed regularly to guide treatment intensification and/or deescalation. It is important that frailty measures are incorporated in clinical trials evaluating novel treatments to inform how older and frail patients will benefit from these treatments.

Background: In-hospital cardiac arrest (IHCA) is associated with significant morbidity and mortality. The relationships of race/ethnicity and sex to outcomes and treatment patterns among patients with IHCA remain poorly understood. Methods: We conducted a retrospective cohort study using the National Inpatient Sample database from 2016 to 2020 to identify adult patients with IHCA and compare in-hospital outcomes stratified by race/ethnicity (White, Black, Hispanic) and sex. The primary outcome was in-hospital mortality. Secondary outcomes included rates of in-hospital procedures. Multivariable logistic regression was used to adjust for potential confounders. Results: Among 207,770 patients with IHCA, 26.6% had ventricular tachycardia/fibrillation (VT/VF) and 73.4% had pulseless electrical activity (PEA)/asystole. In the VT/VF subgroup, Black males (aOR 1.42, 95% CI 1.21-1.66), Black females (aOR 1.25, 95% CI 1.05-1.50), and Hispanic females (aOR 1.30, 95% CI 1.01-1.66) had higher odds of mortality compared to White males (Figure 1). In the PEA/asystole subgroup, Black males (aOR 1.25, 95% CI 1.11-1.39) and Hispanic males (aOR 1.22, 95% CI 1.07-1.40) had higher odds of mortality, while White females had lower odds (aOR 0.88, 95% CI 0.82-0.94) compared to White males (Figure 2). Black patients were less likely to receive percutaneous coronary intervention (aOR 0.53, 95% CI 0.43-0.66 for males; aOR 0.54, 95% CI 0.42-0.69 for females) and coronary artery bypass grafting (aOR 0.50, 95% CI 0.30-0.82 for males; aOR 0.47, 95% CI 0.27-0.81 for females) compared to White males in VT/VF arrests. Additionally, Black males had the highest adjusted odds of renal replacement therapy in VT/VF arrests (aOR 1.47, 95% CI 1.21-1.80), while Hispanic males had the highest adjusted odds in PEA/asystole arrests (aOR 1.49, 95% CI 1.27-1.74) compared to White males. The remaining outcomes of interest in both VT/VF and PEA/asystole arrests are shown in Figure 1 and Figure 2 respectively. Conclusion: Significant racial/ethnic and sex disparities exist in outcomes and treatment patterns among patients with IHCA, with differences observed in both VT/VF and PEA/asystole subgroups. Targeted efforts and further studies are needed to better understand and address these disparities and improve outcomes in these severely ill patients.

Background In‐hospital cardiac arrest (IHCA) is associated with significant morbidity and mortality. The relationships between race and ethnicity and sex on outcomes and treatment patterns among patients with IHCA remain poorly understood. Methods and Results We conducted a retrospective study using the National (Nationwide) Inpatient Sample (NIS) database from 2016 to 2020 to identify adult patients with IHCA and examine the associations between in‐hospital outcomes and race and ethnicity (White, Black, Hispanic) and sex. The primary outcome was in‐hospital mortality. Secondary outcomes included rates of in‐hospital procedures. Multivariable logistic regression analysis was used to adjust for potential confounders. Among 207 770 patients with IHCA, 26.6% had ventricular tachycardia/ventricular fibrillation and 73.4% had pulseless electrical activity/asystole. For ventricular tachycardia/ventricular fibrillation arrest, Black men (adjusted odds ratio [aOR], 1.42 [95% CI, 1.21–1.66]), Black women (aOR, 1.25 [95% CI, 1.05–1.50]), and Hispanic women (aOR, 1.30 [95% CI, 1.01–1.66]) had higher odds of mortality compared with White men (corresponding adjusted risk ratios [aRRs], 1.10 [CI, 1.06–1.14], 1.06 [95% CI, 1.02–1.11], and 1.08 [95% CI, 1.01–1.14], respectively). In the pulseless electrical activity/asystole arrest subgroup, Black men (aOR, 1.25 [95% CI, 1.11–1.39]) and Hispanic men (aOR, 1.22 [95% CI, 1.07–1.40]) had higher odds of mortality (corresponding aRRs, 1.04 [95% CI, 1.02–1.06] and 1.04 [95% CI, 1.01–1.06], respectively). Black patients with IHCA were less likely to receive percutaneous coronary intervention, coronary artery bypass grafting, and mechanical circulatory support compared with White men. Conclusions Significant racial and ethnic and sex disparities exist in outcomes and treatment patterns among patients with IHCA. Targeted efforts and further studies are needed to better understand and address these disparities and improve outcomes.

Abstract Context Patients with adrenal insufficiency (AI) have both increased risk of cardiovascular disease and adverse outcomes with many medical emergencies. However, limited data exist specifically regarding ST-segment elevation myocardial infarction (STEMI) in the context of AI. Objective To evaluate associations between AI and in-hospital outcomes of patients with STEMI. Methods Admissions for STEMI were identified in the 2016-2019 National Inpatient Sample. In-hospital outcomes were compared between patients with and without AI. The primary outcome was in-hospital mortality. Secondary outcomes included percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), intervention, acute kidney injury (AKI), vasopressor use, mechanical circulatory support (MCS), mechanical ventilation, ventricular tachycardia (VT), hospital length of stay (LOS), and total charges. Multivariable regression models were used to adjust for potential confounders. Results Among 690 430 STEMI hospitalizations, 1382 (0.2%) had a diagnosis of AI. AI was associated with higher odds of in-hospital mortality (adjusted OR [aOR] 1.51, 95% CI 1.03-2.2), lower odds of PCI (aOR 0.73, 95% CI 0.55-0.98), higher odds of CABG (aOR 2.8, 95% CI 1.89-4.2) and, AKI (aOR 2.38, 95% CI 1.72-3.3), VT (aOR 1.55, 95% CI 1.1-2.2), need for vasopressors (aOR 2.34, 95% CI 1.33-4.1), mechanical ventilation (aOR 2.11, 95% CI 1.54-2.89), and MCS (aOR 2.18, 95% CI 1.57-3.03). Patients with AI also had a longer LOS (10 days vs 4.2 days, P &lt; .001) and higher charges ($258 475 vs $115 505, P &lt; .001). Conclusion Patients with AI admitted for STEMI had higher in-hospital mortality, nonfatal adverse outcomes, and resource utilization than patients without AI.