Citations

Importance Recent case reports suggest that B antigen–containing blood products may be associated with anaphylactic transfusion reactions in recipients with preformed immunoglobulin E to galactose- α -1,3-galactose (alpha-gal). Objective To test the association of local alpha-gal syndrome (AGS) prevalence and allergic transfusion reaction (ATR) in patients with blood type O. Design, Setting, and Participants In this international, multicenter, retrospective cohort study at academic medical centers, sites were assigned to AGS high- or low-prevalence clusters based on the known geographic distribution of AGS. Data were collected on platelet or plasma transfusions and ATRs during 2020 to 2024. Consecutive patients receiving platelet or plasma transfusions were included. Exposures Patients with blood type O who received B or AB units and patients with blood type O who received O units (reference group) in AGS high- and low-prevalence clusters were compared. Main Outcomes and Measures Before data collection, the hypothesis was that if transfusion-related alpha-gal syndrome (TRAGS) is a true clinical entity, excess ATRs to group B or AB units would be detected in AGS high-prevalence regions exclusively. The main measure was the overall risk ratio (RR) for ATRs to B or AB plasma or platelets in AGS high- vs low-prevalence clusters. Results In total, 558 823 platelet and plasma transfusions at 40 sites in 5 countries were analyzed, of which ATRs occurred in 1744 transfusions (0.3%). In the US AGS high-prevalence cluster (9 sites), significantly more ATRs of any severity occurred among patients with blood type O who received B or AB units vs patients with blood type O who received O units (overall RR, 3.93; 95% CI, 2.96-5.21; P < .001). In contrast, in the primary analysis of the AGS low-prevalence cluster (15 sites), excess ATRs to B or AB units were not detected. In subgroup analyses among patients with blood type O receiving B units, the RR for moderate to severe ATRs was 9.14 (95% CI, 5.39-15.52; P < .001) in the AGS high-prevalence cluster vs 2.15 (95% CI, 1.34-3.47; P = .002) in the AGS low-prevalence cluster. Outside the US, a signal consistent with TRAGS was not detected. Conclusions and Relevance This cohort study provides provocative epidemiologic evidence that TRAGS may be a unique manifestation of AGS and a previously unrecognized risk associated with transfusion. In AGS high-prevalence regions, blood collectors and hospital transfusion services should consider approaches to preventing severe ATRs from B or AB plasma or platelet units.

Newborn screening (NBS) for inborn errors of metabolism is challenged by high false-positive rates, which may lead to parental anxiety and increased healthcare costs associated with diagnostic follow-up. False-positive results often arise from changes in metabolite concentrations that mimic metabolic disorders as a consequence of differences in perinatal factors or nutritional status. To address this, Collaborative Laboratory Integrative Reports (CLIR) and the associated post-analytical tools (PATs) using multivariate interpretation and covariate-adjusted reference intervals may be used to improve specificity of NBS algorithms. In the current study, we examined whether CLIR can be applied to optimize the Dutch NBS program by reducing the false-positive rates. We developed and validated a CLIR-based PAT for CPT1 deficiency, GA-I, IVA and MSUD within the Dutch NBS program. Single-condition tools (SCTs) and multivariate approaches, including marker ratios and covariate adjustments, were evaluated for their ability to discriminate true- and false-positive referrals. For CPT1 deficiency, age-adjusted SCT combined with birthweight, location correction, and the C18:1/methionine ratio substantially reduced false positives. For GA-I, C3DC-based ratios improved specificity while preserving true-positive detection, potentially reflecting postnatal renal immaturity in some cases. For IVA, the dual scatter plot fully separated true- and false-positive referrals, highlighting the limitations of single-marker screening. For MSUD, differences between false-positive and true-positive cases were more pronounced, yet a similar number of false positives were still referred; valine-related markers contributed to false positives, while leucine and the Xle/Phe ratio better identified true positives. CLIR-based post-analytical tools enhanced NBS specificity through covariate-aware, multivariate interpretation. This provides important input for decision makers in both the Dutch NBS, as well as the NBS community worldwide.

Abstract High-frequency oscillations (HFOs) are clinically established biomarkers of epileptogenic tissue, yet their translation from hospital-based recording systems to implantable neural interfaces remains a major barrier to their utilization in adaptive neuromodulation in epilepsy. Here, we established a bedside translational framework using a benchtop implementation of a wireless implantable neural interface (Brain Interchange, BIC) to evaluate whether clinically meaningful HFO can be preserved under implant-grade sensing constraints. Ten patients with drug resistant epilepsy underwent simultaneous 24-hour intracranial EEG recordings using synchronized BICs and a clinical-grade amplifier. A sensitive detector identified candidate HFOs, while sparse signal processing and machine learning methods removed artifact related pseudo-HFOs. Despite its lower sampling rate, narrower analog bandwidth, and higher noise floor, the integrated sensing and computational intelligence framework preserved approximately 82% of clinical amplifier HFOs and maintained nearly identical spatial distribution of pathological activity. After pseudo-HFO elimination, BIC derived HFOs localized the seizure onset zone with 84% sensitivity and 90% specificity, comparable to the clinical amplifier despite lower fast ripple detection. These findings demonstrate that implant-grade neural sensing, when integrated with artifact resilient computational intelligence, can preserve clinically relevant HFO biomarkers and their spatial fidelity without reproducing every individual electrophysiological event. More broadly, this work establishes a translational framework for chronic tracking of evolving epileptogenic networks and future biomarker-guided adaptive neuromodulation.

Since October 2019, screening for methylmalonic acidemia (MMA) has been implemented in the Dutch Newborn Screening (NBS) program. Since implementation, most referrals for MMA have been the result of (maternal) vitamin B12 deficiency. Although vitamin B12 deficiency is an important condition and early detection can confer health benefits, its identification was not the original objective of the screening. We therefore examined whether genetic forms of MMA can be distinguished from acquired forms. Early distinction between these forms is essential for guiding clinical management, informing prognosis, and enabling appropriate genetic counseling. Specifically, we tested whether the use of Collaborative Laboratory Integrated Reports (CLIR) to complement NBS results improved specificity of the test for genetic MMAs. We found that with the use of CLIR, genetic conditions including methylmalonyl-CoA mutase (mut) deficiency and cobalamin (cbl) A, B, C and D deficiency can be partially differentiated from acquired causes. This results in a significant reduction in the number of second-tier tests required. However, this approach may also exclude certain other genetic causes. Based on all findings, we provide considerations and implications for MMA screening that may inform decision-makers in (other) NBS programs.

Background: Telogen effluvium (TE) is one of the most common forms of nonscarring alopecia. TE typically presents as sudden diffuse shedding of hair, and generally occurs 3–4 months after a triggering event such as physiological or psychological stress, certain medications, or hormonal changes. Despite the high prevalence of TE, no standardized clinical guidelines for the management of this condition currently exist. Objective: To address the lack of standard clinical guidelines for the management of TE, a multidisciplinary panel of dermatologists, dermatology advanced practice providers, and primary care providers convened to evaluate current evidence related to the treatment of TE. Methods: The primary research team, composed of 13 individuals, completed a comprehensive literature review of TE treatment. Then an expert panel conducted 2 rounds of article review, assessing each article based on the Strength of Recommendation Taxonomy (SORT) criteria and formulating consensus statements based on this data. An expert panel of 20 clinicians then evaluated the statements utilizing a structured eDelphi consensus process. Results: A total of 18 consensus statements regarding treatment recommendations for TE were reviewed by the expert panel. Of these, 3 statements addressed acute TE, while 15 focused on chronic TE. The panel evaluated each statement through open forum discussion, followed by voting and modification using the eDelphi methodology. Ultimately, 16 statements reached consensus following 2 rounds of the eDelphi survey. Conclusion: The self-limiting nature of acute TE warrants patient education, but no specific therapies were found to improve outcomes compared with placebo. While there is a gap in quality research regarding chronic TE treatment, current evidence suggests that topical minoxidil, vitamin D supplementation, and platelet-rich plasma may provide benefit in chronic TE based on individual clinical judgement.

Abstract. Introduction: Preterm birth drives adverse perinatal maternal and infant health outcomes through heterogeneous symptoms, severity, and etiologies. Delivery prior to reaching 37 weeks of gestation may result from medically indicated intervention for pregnancy complications or spontaneously in the absence of prior symptoms. Placental tissue collected following preterm birth exhibits differential DNA methylation compared to full-term placentas and may indicate pregnancy health during gestation. Placental DNA currently has limited utility for assessing health of ongoing pregnancy, as sampling placental tissue during gestation increases the risk of infection and miscarriage. Risks associated with placental sampling during pregnancy limit the use of DNA methylation in clinical preterm birth prediction. Assessing preterm birth risk during gestation requires non-invasive methods for characterizing placental DNA methylation. Results: We quantified genome-wide DNA methylation patterns of hypermethylated cell-free DNA in pregnant (n = 99) and non-pregnant (n = 93) plasma using cell-free methylated DNA immunoprecipitation sequencing (cfMeDIP-seq). In each sample, we assessed DNA methylation status in 300-bp genomic windows, examining both sequencing read counts and calculated absolute molar DNA amount. Known hypermethylated placental regions, including RASSF1, STAT5A, and ERG promoters showed significantly increased odds of detection in pregnant samples, suggesting enrichment of cell-free placental DNA. Of the 536,444 300-bp windows examined, 173,071 (32%) showed significant enrichment in pregnant plasma. Linear modeling identified 107,505 differentially methylated regions (DMRs) associated with pregnancies later diagnosed with intrauterine growth restriction (IUGR) (n = 22). Alu elements showed increased representation in these DMRs than expected, while other repetitive elements exhibited underrepresentation. Discussion: These results demonstrate cfMeDIP-seq's ability to enrich for cell-free placental DNA and characterize cell-free DNA methylation signatures of pregnancies complicated by IUGR. Enrichment of cell-free placental DNA enables non-invasive profiling of placental DNA methylation from maternal plasma. Detectable epigenetic signatures in maternal plasma may identify pregnancies at elevated risk for preterm birth before clinical symptoms appear. Our findings further highlight the potential of cell-free placental DNA for monitoring pregnancy health.

Abstract Background Synthetic control arms (SCAs) derived from historical trial data can complement randomized controlled trials (RCTs), particularly in oncology where feasibility, ethical, and cost constraints may limit conventional trial designs. However, their validity for overall survival (OS) remains uncertain. We evaluated the feasibility and limitations of constructing SCAs from the ARCAD metastatic colorectal cancer (mCRC) database across multiple treatment lines. Methods Seven landmark RCTs representing first-, second-, and third-line settings were selected. External control arms were constructed from ARCAD individual patient-level data using propensity score matching based on key clinical and biological variables from a validated ARCAD prognostic score, with adjustment for geographic region and time era when needed. A prespecified two-step benchmarking framework assessed: (1) control-arm OS reproducibility and (2) virtual trial comparisons between matched synthetic controls and original RCT experimental arms. Agreement was evaluated using hazard ratios (HRs) and Z-tests. Results A total of 28,022 patients met the inclusion criteria. ARCAD-derived SCAs were successfully constructed for all selected RCTs and closely reproduced control-arm OS. After matching, baseline characteristics were well balanced, with minimal differences between included and excluded patients. Virtual trials showed concordant treatment-effect estimates with the original RCTs, with a median absolute HR deviation of 0.05 and no significant differences by Z-tests (P>.05). Survival outcomes were consistently reproduced across treatment lines. Conclusion ARCAD-derived SCAs reliably reproduced control-arm OS and benchmark treatment-effect estimates from landmark RCTs in mCRC. Despite limitations related to residual confounding and missing data, this framework supports benchmarking, trial design, and exploratory analyses when conventional control arms are impractical.

Abstract Purpose Traditional adverse event (AE) reporting in oncology trials focuses on the single worst CTCAE grade, which may underrepresent chronic or recurrent toxicity burden. We applied a longitudinal toxicity framework to compare toxicity profiles of chemotherapy with or without cetuximab in metastatic colorectal cancer. Patients and Methods We pooled two randomized first-line trials in the ARCAD database. AEs examined were diarrhea, rash, hand-foot syndrome (HFS), fatigue, anorexia, and mucositis. Outcomes included grade ≥3 AE, time to first occurrence of maximum grade, early onset (≤6 weeks), and AEL, a normalized measure of cumulative toxicity burden over treatment. Analyses were adjusted for chemotherapy backbone, ECOG performance status, sex, primary tumor location, dose reduction, and treatment duration. Results Compared with Chemotherapy alone (n = 564), Chemotherapy plus cetuximab (n = 738) was associated with higher grade ≥3 rash (21% vs 0.5%; adjusted odds ratio [OR] 49.89, 95% CI 15.8–157.4), higher rash AEL (0.257 vs 0.069; adjusted mean difference 0.22, 95% CI 0.21–0.23), and more frequent early-onset maximum rash (67% vs 34%; adjusted OR 4.28, 95% CI 2.72–6.74). Rash AEL remained higher with cetuximab within maximum-grade strata. HFS showed higher grade ≥3 risk and overall AEL with cetuximab, but no within-grade AEL difference, indicating higher overall HFS burden reflected grade distribution rather than within-grade chronicity. No consistent differences were observed for other AEs. Conclusions Incorporating onset timing and AEL distinguished persistent toxicity burden from isolated peak events. This framework may support comparative tolerability assessment when chronic toxicity burden is central to decision-making.

Background: Increased posterior tibial slope (PTS) has been associated with higher revision rates after anterior cruciate ligament reconstruction (ACLR). Whether the addition of lateral extra-articular tenodesis (LET) mitigates the risk associated with increased PTS is unclear. Purpose: To determine the prevalence of increased PTS (≥12°) in a young high-risk primary ACLR population and evaluate whether LET is associated with lower revision rates in patients with increased PTS. Study Design: Cohort study; Level of evidence, 3. Methods: This study included patients aged ≤25 years undergoing primary ACLR across 3 high-volume centers with ≥2 years between surgery and data collection. PTS was measured on lateral radiographs for medial and lateral plateaus. Primary analyses consisted of 4 prespecified multivariable logistic regression models with different PTS operationalizations as continuous predictors per 1° increase (medial PTS, lateral PTS, the maximum [PTSmax], and the lateral-medial difference), adjusted for patient and surgical covariates including graft type, with surgical center as a fixed effect. Secondary analyses used PTS dichotomized at 12°; revision rates were compared between isolated ACLR and ACLR with LET, with the treatment effect quantified as absolute risk reduction and number needed to treat. Results: A total of 780 patients were included; 84 (10.8%) underwent revision ACLR. Increased PTS (≥12°) was present in 28.2% of patients and more common in those requiring revision (38.6% vs 27.0%; P = .03). In patients with PTSmax ≥12°, revision occurred in 21.0% without LET and 9.2% with LET (absolute risk reduction, 11.8% [95% CI, 2.3%-21.3%]; number needed to treat, 9); in patients with PTSmax <12°, revision occurred in 13.2% without LET and 5.4% with LET (absolute risk reduction, 7.8% [95% CI, 3.0%-12.6%]; number needed to treat, 13). In the 4 prespecified multivariable models with PTS as a continuous predictor, LET was independently associated with substantially lower odds of revision ACLR (odds ratio [OR], 0.37; 95% CI, 0.22-0.62; P < .001). Lateral PTS (OR, 1.09 per 1° increase; 95% CI, 1.00-1.18; P = .04) and PTSmax (OR, 1.09; 95% CI, 1.00-1.19; P = .04) were independently associated with revision ACLR. The lateral-medial PTS difference was not associated with revision ACLR. Conclusion: In a young high-risk primary ACLR population, increased PTS was present in nearly 30% of patients. LET was associated with a lower risk of revision irrespective of PTS, while increased PTS was independently associated with revision ACLR.