Citations

Case: An upper trunk brachial plexus injury patient underwent ulnar motor fascicular to biceps motor nerve transfer. At 6 months postoperative, the patient had trace biceps firing but was diagnosed with an unrecognized rupture of the distal biceps tendon, requiring reconstruction. Another patient with C5-T1 injury was noted to have distal biceps tendon rupture at the time of gracilis muscle transfer. Both patients had gravity-assisted elbow flexion at 1-year follow-up. Conclusion: Biceps rupture is an uncommon concomitant injury with brachial plexus trauma and challenging to diagnose in the context of a paretic limb. Thorough history and intraoperative biceps tendon palpation will ensure these injuries are identified.

9002 Background: The field of AI is rapidly evolving. With recent development of more user-friendly AI software, its integration into healthcare across different medical specialties, including HemOnc has emerged. Data detailing the perception and concerns of the HemOnc workforce about AI’s roles is lacking and is needed if AI is to be integrated in HemOnc CliPr and MedEd. Methods: Questionnaires about the perception and concerns regarding AI in CliPr and MedEd were created on REDCap and approved by IRB. We surveyed the entire HemOnc workforce at the 3 Mayo Clinic major sites between 11/07/24 and 01/20/25, including physicians, both faculty (FAC) and fellows (FEL), advanced practice providers (APP), and nurses (RN). Participation was voluntary. Simple statistical analyses were employed for the results. Results: 344 participants (PTP) responded to the survey, 118 physicians (41 FEL and 77 FAC), 49 APP, and 177 RN. 64% of PTP report having used AI but only 31% used it in HemOnc MedEd, and 28% in HemOnc CliPr, with 67% considering themselves to have little to no knowledge about AI. 94% of PTP believe AI will be integrated in HemOnc MedEd, with such integration being seen as beneficial by 90%. Among physicians, 85% of FEL and 92% of FAC report that fellowship programs should incorporate AI training into curricula. 95% of PTP believe AI will be incorporated into HemOnc CliPr. Meanwhile, 62% of PTP (50.8% of physicians, and 68% of APP and RN) are concerned about risks it may pose to CliPr. Nevertheless, 90% of PTP would embrace AI’s use in HemOnc. Table 1 details the perceptions and concerns about AI in HemOnc MedEd and CliPr. The main perceived risks are decreased time spent with patients (pts), and inaccuracies or worse pt care. Meanwhile, 33% believe AI would increase efficiency and quality of care, while 30% believe it would increase time spent with pts. 14% of PTP worry their role could be replaced by AI. Conclusions: To the best of our knowledge, this is the largest assessment of HemOnc workforce’s perception and concerns about AI. Based on our survey, the HemOnc workforce, in general, endorses AI use, but with some concerns raised. While incorporation in MedEd is perceived with excitement, many envision the use in CliPr involves risks and challenges. Proper systematic education of the workforce about AI, with well-designed CliPr integration methods are needed to mitigate the legitimate existing concerns. Perceptions & concerns about AI in HemOnc MedEd & CliPr. FEL % APP % RN % FAC % AI will assist documentation in CliPr 98 82 79 92 AI will be used in pt communication 73 80 78 87 AI will screen pts for clinical trial enrollment 85 86 76 96 AI will increase the efficiency and quality of CliPr 43 37 24 46 AI will increase time spent with pts 39 27 25 38 AI will decrease time spent with pts 29 41 48 23 AI will lead to inaccuracies or worse CliPr 12 20 25 20 AI may replace the HemOnc workforce 11 16 19 5

ABSTRACTImmune thrombotic thrombocytopenic purpura (iTTP) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and microvascular occlusion secondary to acquired ADAMTS13 deficiency. Contemporary data regarding iTTP treatment practices in the US, including the use of caplacizumab, are lacking. We aimed to characterize the demographics and therapies, including medications and apheresis practices, in patients with iTTP in the US. We retrospectively analyzed iTTP cases at 15 sites in the US that provide comprehensive care for patients with iTTP. The time‐period assessed was from January 1, 2017 to December 31, 2021. Our primary objective was to analyze data by iTTP episode, inclusive of initial episodes and relapses. A total of 390 iTTP episodes were reported for 280 unique individuals (187 females, 93 males). Thirty‐day mortality was 3.7% (14/374), and 6‐month mortality was 7.4% (27/367). TPE details were reported for 343 episodes, among which 261 underwent at least one procedure (median 6, IQR 3–11). Among the 261 episodes with at least one therapeutic plasma exchange (TPE) performed, 82.0% (214/261) used only plasma. Caplacizumab was used either alone or in combination with other agents in 43 (11.0%) episodes. Management strategies for iTTP remain varied across centers in the US, with a variety of combinations for TPE replacement fluids and therapeutic agents, as well as limited use of caplacizumab. Further research and standardization of treatment regimens may further reduce mortality in this condition.

206 Background: XTX101 is an investigational tumor-activated, Fc-enhanced, high affinity binding aCTLA-4 designed to block CTLA-4 and deplete regulatory T cells upon activation in the tumor by proteases. XTX101 also contains mutations designed to enhance Fcγ receptor binding. Fc enhancement augments FcγR co-engagement on antigen presenting cells and has been linked with efficacy of aCTLA-4 combinations in patients (pts) with “cold tumors”, including microsatellite stable (MSS) colorectal cancer (CRC). Parts 1A/1B of the study evaluated XTX101 monotherapy in pts with advanced solid tumors. XTX101 was generally well tolerated with limited peripheral XTX101 activation (~13%) compared to evidence of XTX101 activation in the tumor microenvironment (73-96%, in n=2 on-treatment tumor biopsies). A durable partial response (PR) and resolution of hepatic metastases was observed in a pt with PD-L1 negative NSCLC at the monotherapy recommended phase 2 dose (RP2D) of 150 mg once every six weeks (Q6W) [1]. Methods: Part 1C evaluated the safety and feasibility of XTX101 in combination with atezolizumab in pts with advanced solid tumors using 3+3 dose escalation to establish the RP2D. Phase 2 is enrolling pts with MSS CRC with at least 1 prior regimen for metastatic CRC. Initial safety and anti-tumor activity data from Phase 2 in ~20 pts will be presented. Results: As of July 15, 2024, 15 pts were enrolled in Part 1C: MSS CRC (n=12), esophageal cancer, NSCLC, and ampullary carcinoma (n=1 each). Median age 69 and 3 prior lines of therapy (1-12). Across all XTX101 dose levels (75 mg to 150 mg), treatment-related adverse events (TRAEs) of any grade with >10% incidence included infusion reactions (n=4), fatigue and diarrhea (n=2 each), no G4 or G5 TRAEs were reported. In Part 1C, 2 pts experienced a dose limiting toxicity: 1 pt had G3 colitis, and 1 pt had G3 liver enzyme elevation (both were at the XTX101 150 mg dose level and resolved with immunosuppression). Two unconfirmed PRs were reported: in a pt with MSS CRC, including resolution of a liver target lesion, and in a pt with ampullary carcinoma (accompanied by a Ca 19-9 decrease from 700 to 41). In addition, a decrease in intra-tumoral Tregs was observed in paired tumor biopsies from a pt. The combination RP2D was established as XTX101 100 mg Q6W and atezolizumab 1200 mg once every three weeks (Q3W), and enrollment in the Phase 2 part of the study for pts with MSS CRC is ongoing at the RP2D. Conclusions: In Part 1C dose escalation, the combination of XTX101, a tumor-activated, Fc-enhanced aCTLA-4, and atezolizumab was generally well tolerated in pts with advanced solid tumors and demonstrated initial evidence of anti-tumor activity in cold tumors. These data support the initiation of an ongoing Phase 2 study evaluating the combination in pts with MSS CRC with and without liver metastases. 1. Davar ESMO IO 2023. Clinical trial information: NCT04896697 .

ImportanceRetrieval strategies for children, adolescents, and young adults with relapsed classic Hodgkin lymphoma (cHL) aim to maintain efficacy while minimizing long-term toxic effects. Children, adolescents, and young adults with low-risk, relapsed cHL may benefit from replacing high-dose chemotherapy and autologous stem cell transplant with less intensive involved-site radiotherapy (ISRT).ObjectiveTo evaluate a risk-stratified, response-adapted, transplant-free approach for treatment of children, adolescents, and young adults with low-risk relapsed cHL with nivolumab plus brentuximab vedotin (BV) followed by BV plus bendamustine for patients with suboptimal response and ISRT (30.0 to 30.6 Gy).Design, Setting, and ParticipantsCheckMate 744 (R1 cohort) was a phase 2, nonrandomized, single-arm study enrolling children, adolescents, and young adults aged 5 to 30 years with low-risk cHL between September 25, 2017, and December 16, 2020, across the US, Canada, and Europe. Data were analyzed from September 2017 to November 2022.ExposuresPatients received 4 cycles of nivolumab plus BV induction; patients with complete metabolic response (CMR) received an additional 2 cycles of nivolumab plus BV while patients with suboptimal response received 2 cycles of BV plus bendamustine intensification. Patients with CMR after induction or intensification received ISRT consolidation.Main Outcomes and MeasuresPrespecified coprimary end points were CMR rate (Lugano 2014 classification) any time before ISRT and 3-year event-free survival (EFS) rate, per blinded independent central review (BICR).ResultsOf 28 included patients treated in the low-risk cohort, 18 (64%) were female, and the median (range) age was 17 (6-27) years. At a median (range) follow-up of 31.9 (2.2-55.3) months, CMR per BICR any time before ISRT was 93% (26 of 28; 90% CI, 79.2-98.7; objective response rate [ORR], 100%), and 23 of 28 (82%) achieved CMR per BICR after 4 cycles of nivolumab plus BV (ORR, 96.4%). Kaplan-Meier estimates of EFS and progression-free survival rates at 3 years were 87% (3 of 18; 90% CI, 69.5-94.7) and 95% (1 of 18; 90% CI, 76.7-99.0), respectively. During induction, 22 patients (79%) had treatment-related adverse events, including 7 with grade 3 or 4 adverse events, 2 with anemia, 1 with neutropenia, and 6 with immune-mediated adverse events. Serious adverse events leading to discontinuation occurred in 2 patients.Conclusions and RelevanceThis nonrandomized clinical trial found that for children, adolescents, and young adults with low-risk, relapsed cHL, a transplant-free, risk-adapted, response-based approach with nivolumab plus BV and ISRT offered high CMR rates and high 3-year EFS rate, with a safety profile consistent with that of each agent used.Trial RegistrationClinicalTrials.gov Identifier: NCT02927769

Background: The number of hip arthroscopies performed in the United States has grown significantly over the past several decades, with evolving indications and emerging techniques. Purposes: To (1) examine the evolution of hip arthroscopy at 3 tertiary referral centers between 1988 and 2022 and (2) quantify trends in patient demographics and procedures performed. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis was performed of all patients undergoing hip arthroscopy at 3 academic centers between 1988 and 2022. Demographic data were collected using standardized forms and operative notes, and intraoperative images were manually reviewed for each patient to determine the specific procedures performed at the time of the hip arthroscopy. Surgical procedures were plotted over time to evaluate trends. Patients were divided into 3 time periods for comparison: early hip arthroscopy from 1988 to 2008, 2009 (the time of the first labral repair in our cohort) to 2015, and 2016 to 2022. Results: A total of 3000 patients (age, 35.7 ± 13.8 years; age range, 10-89 years; female sex, 2109 (70.3%); body mass index, 27.4 ± 6.3 kg/m 2 ) underwent arthroscopic hip procedures between 1988 and 2022. The mean number of cases increased from a mean of 3.2 per year in 1988-2008 to 285.9 per year in 2016-2022 ( P < .001). Labral treatment at the time of primary hip arthroscopy evolved from 100% debridement and 0% repair in 1988-2008 to 5.0% debridement, 94.0% repair, and 1.0% labral reconstruction in 2016-2022 ( P < .001). Cam resection increased from 4.1% in 1988-2008 to 86.9% in 2016-2022 ( P < .001). By 2022, 45 out of 325 cases (13.8%) were revisions. The rate of capsular repair at the time of primary hip arthroscopy increased from 0.0% in 1988-2008 up to 81.0% in 2016-2022. Conclusion: There has been a significant growth of hip arthroscopy volumes as well as a significant transition from use as a tool for diagnosis and labral debridement to procedures restoring native anatomy including labral repair, cam resection, capsular repair, periacetabular osteotomy, and gluteal repair.

AbstractBackgroundHemolytic disease of the fetus and newborn (HDFN) is caused by maternal alloantibody‐mediated destruction of fetal/neonatal red blood cells (RBCs). While the pathophysiology has been well‐characterized, the clinical and laboratory monitoring practices are inconsistent.MethodsWe surveyed 103 US institutions to characterize laboratory testing practices for individuals with fetuses at risk of HDFN. Questions included antibody testing and titration methodologies, the use of critical titers, paternal and cell‐free fetal DNA testing, and result reporting and documentation practices.ResultsThe response rate was 44% (45/103). Most respondents (96%, 43/45) assess maternal antibody titers, primarily using conventional tube‐based methods only (79%, 34/43). Among respondents, 51% (23/45) rescreen all individuals for antibodies in the third trimester, and 60% (27/45) perform paternal RBC antigen testing. A minority (27%, 12/45) utilize cell‐free fetal DNA (cffDNA) testing to predict fetal antigen status. Maternal antibody titers are performed even when the fetus is not considered to be at risk of HDFN based on cffDNA or paternal RBC antigen testing at 23% (10/43) of sites that assess titers.DiscussionThere is heterogeneity across US institutions regarding the testing, monitoring, and reporting practices for pregnant individuals with fetuses at risk of HDFN, including the use of antibody titers in screening and monitoring programs, the use of paternal RBC antigen testing and cffDNA, and documentation of fetal antigen results. Standardization of laboratory testing protocols and closer collaboration between the blood bank and transfusion medicine service and the obstetric/maternal‐fetal medicine service are needed.

Objectives: Medial meniscus posterior root tears (MMPRTs) render the meniscus essentially non-functional, resulting in increased peak contact pressures, reduced forced dissipation, and increased risk of early osteoarthritis. Transtibial root repair has shown promise at restoring meniscus function and improving clinical outcomes; however, a paucity of literature exists evaluating the prognostic clinical and radiographic factors for poor outcomes following isolated meniscus root repair. The purpose of this study was to 1) describe the patient reported clinical outcomes after isolated MMPRT repair at minimum 2-year follow-up, 2) determine the retear and conversion to arthroplasty rates, and 3) identify prognostic factors for clinical outcomes and International Knee Documentation Committee (IKDC) Patient Acceptable Symptom State (PASS) achievement. Methods: Isolated MMPRT repairs from 2010-2020 at three institutions in Rochester, MN; Jacksonville, FL; and Phoenix, AZ were followed prospectively for postoperative Tegner Activity Scale, Visual Analog Scale (VAS) for pain, IKDC, Forgotten Joint Score (FJS), subjective improvement and knee preference, and subsequent surgeries at minimum 2-year follow up. PASS for IKDC was set at 69. Demographics, injury characteristics, and surgical details were collected. Results: Eighty-four patients were included in this study (age: 49.7 ± 11.0 years [range: 13-76]; sex: 75.0% female; BMI: 31.6 ± 6.9 kg/m 2 [MH1] ). Forty-five patients (53.6%) had BMI >30 kg/m 2 , and 14 patients (16.7%) reported a history of active smoking (Table 1). Mean medial compartment Outerbridge grade was 2.0 ± 1.1, with 73.8% of patients having grade ≥2 changes. Mean preinjury Tegner score, preoperative VAS at rest, and preoperative VAS with use were 4.6 ± 2.4, 3.6 ± 2.7, and 6.5 ± 2.5, respectively. At final follow-up (mean 3.9 ± 2.0 years), mean Tegner score was 4.3 ± 1.8, mean VAS at rest was 1.2 ± 2.0, and mean VAS with use was 2.3 ± 2.2. There was no significant difference in preinjury vs. postoperative Tegner scores (p = 0.208), and preinjury Tegner was significantly positively correlated with postoperative Tegner (p < 0.001). Significant (p < 0.001) postoperative improvements in both VAS at rest and with use were observed. Mean postoperative IKDC score was 73.3 ± 17.0, and mean FJS was 59.6 ± 27.9 at final follow-up. When asked to rate their knee at final follow-up compared to before surgery on a scale from 0-5 (0 = “significantly worse”, 1 = “mildly worse”, 3 = “unchanged”, 4 = “mildly improved”, 5 = “significantly improved”), the mean score 4.6 ± 0.8. Forty-one patients (74.5%) reported significant improvement, 8 (14.5%) reported mild improvement, 3 (5.5%) reported no change, and 3 (5.5%) reported mild worsening. No patients reported significant worsening. When asked which knee they preferred, 13 patients (26.0%) reported preferring their operated knee, compared to 18 (36.0%) who preferred their nonoperated knee. The remaining 19 patients (38.0%) had no preference for one knee over the other. A summary of all patient reported outcomes is reported in Table 2. At the time of final follow-up, 16 (19.0%) of patients had reached a clinical endpoint. Twenty-nine patients (34.5%) underwent postoperative MRIs at an average of 1.5 ± 1.7 years (range: 0.3-5.9 years) after surgery[MH1] . Twelve of the MRIs (41.4%) were ordered for evaluation of continued pain, while 7 (24.1%) were ordered for new pain or injury, and 10 (34.5%) were ordered for research purposes. Five patients (6.0%) had MRI-confirmed retears of the MMPRT repair at an average of 1.1 ± 1.3 years (range: 0.3-3.4) after surgery[HMMP2] , one of which was in an asymptomatic patient who received a follow-up MRI for research purposes. No patients underwent revision MMPRT repair surgery, and 7 patients (8.3%) progressed to arthroplasty (6 TKA, 1 UKA) at an average of 3.4 ± 4.3 years (range 0.6-12.6), one of whom also sustained a root retear. Therefore, the surgical failure was noted in 11 patients, corresponding to a surgical failure rate of 13.1% in this cohort. Of note, three of the five patients with MRI-confirmed retears had not received any further surgical intervention[MH3] [BA(M4] at the time of final follow-up 2.7, 3.8, and 8.5 years after surgery. Additionally, there were six non-MMPRT revision, non-arthroplasty subsequent surgeries in five patients, and there were three patients (3.6%) who sustained new medial meniscus tears 2.8-, 3.6-, and 5.9-years postoperatively, respectively. A concise summary of clinical endpoints can be found in Table 3 and Table 4. Significantly more females experienced surgical failures than males (17.5% vs. 0%, p = 0.040), and significantly more patients with medial compartment Outerbridge grades ≥2 experienced surgical failure than those with grades <2 (17.7% vs. 0%, p = 0.034). Additionally, patients who failed did have significantly higher mean KL grades than those who did not (1.4 ± 0.9 vs. 0.7 ± 0.7, p = 0.012). There were no other significant differences in the demographic or pathologic characteristics of patients who experienced surgical failure and those who did not. Of note, 37% of patients failed to achieve IKDC PASS, with smoking status associated with a 15-point reduction in IKDC (p=0.010) Conclusions: Patients undergoing transtibial root repair demonstrate restoration of pre-injury activity levels, significant clinical improvements in pain and function, and low surgical failure rates at minimum 2-year follow-up, with 89% of patients reporting subjective improvement after surgery. However, only 63% of patients were able to achieve PASS thresholds, suggesting that while effective, additional research on root repair technical and clinical optimization is warranted.

AbstractPrior studies have suggested that immune thrombotic thrombocytopenic purpura (iTTP) may display seasonal variation; however, methodologic limitations and sample sizes have diminished the ability to perform a rigorous assessment. This 5‐year retrospective study assessed the epidemiology of iTTP and determined whether it displays a seasonal pattern. Patients with both initial and relapsed iTTP (defined as a disintegrin and metalloprotease with thrombospondin type motifs 13 activity <10%) from 24 tertiary centers in Australia, Canada, France, Greece, Italy, Spain, and the US were included. Seasons were defined as: Northern Hemisphere—winter (December–February); spring (March–May); summer (June–August); autumn (September–November) and Southern Hemisphere—winter (June–August); spring (September–November); summer (December–February); autumn (March–May). Additional outcomes included the mean temperature in months with and without an iTTP episode at each site. A total of 583 patients experienced 719 iTTP episodes. The observed proportion of iTTP episodes during the winter was significantly greater than expected if equally distributed across seasons (28.5%, 205/719, 25.3%–31.9%; p = .03). Distance from the equator and mean temperature deviation both positively correlated with the proportion of iTTP episodes during winter. Acute iTTP episodes were associated with the winter season and colder temperatures, with a second peak during summer. Occurrence during winter was most pronounced at sites further from the equator and/or with greater annual temperature deviations. Understanding the etiologies underlying seasonal patterns of disease may assist in discovery and development of future preventative therapies and inform models for resource utilization.

Background: CPR quality is closely linked to outcome in cardiac arrest. The AHA 2010 Guidelines recommend monitoring CPR quality performed by healthcare providers both inside and outside the hospital. However, most EDs currently do not monitor CPR quality. The goal of the present investigation was to assess the quality of CPR performed in an urban ED and determine the influence of training and real-time audiovisual feedback (RTAVF) on CPR quality and patient outcome. Methods: CPR quality was monitored using an R Series defibrillator (ZOLL Medical) during the treatment of adult cardiac resuscitation attempts. During phase 1 (P1; 11/2010-11/2012), real-time audiovisual chest compression feedback was disabled. During phase 2 (P2; 11/2012-3/2013), clinicians underwent a 60 minute didactic/hands-on CPR training session after which the RTAVF and the ECG artifact filtering feature were enabled. CPR quality data (fraction, depth, rate, release, peri-shock pause) were reviewed using Code Review software (ZOLL Medical). Student’s t-test and Wilcoxon-signed rank test were employed. Results: A total of 44 OHCA patients were treated in P1 (mean age 57±18 yrs, 59% male) and 24 in Phase 2 (mean age 63±15 yrs, 88% male). The majority of patients (89% P1; 96% P2) suffered prehospital arrest and were transported to the ED. Chest compression (CC) depth increased from 1.8±0.5 inches in P1 to 2.3±0.4 in P2 (p<0.001), with the percentage of compressions exceeding 2 inches more than doubling from 36% in P1 to 79% in P2 (p<0.001). CC release velocity increased from 1.25±0.36 inch/sec in P1 to 1.69±0.28 in P2 (p<0.001). No significant differences were identified in CC rate (125±12 cpm P1 vs. 121±15 cpm P2, p=0.3) or CC fraction (82% P1 vs. 87% P2, p=0.1). Pre-shock pause (11.5±10.4 sec P1 vs. 8.0±6.2 P2, p=0.4) and post-shock pause (5.2±3.4 sec vs. 3.8±0.6, p=0.9) were statistically similar in P1 and P2. Conclusion: The bundle of real time audiovisual CPR feedback and training were associated with an improvement in chest compression depth and recoil and closer adherence to guidelines for CPR quality in this large urban ED.