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Abstract Background The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. There are currently no guidelines for antimicrobial prophylaxis. We analyzed 7 years of prophylactic antimicrobial use across 3 time series for patients on ECMO at our institution in the development, improvement, and streamlining of our ECMO antimicrobial prophylaxis protocol. Methods In this quasi-experimental interrupted time series analysis, we evaluated the impact of an initial ECMO antimicrobial prophylaxis protocol, implemented in 2014, on antimicrobial use and National Healthcare Safety Network–reportable infection rates. Then, following a revision and streamlining of the protocol in November 2018, we reevaluated the same metrics. Results Our study population included 338 intensive care unit patients who received ECMO between July 2011 and November 2019. After implementation of the first version of the protocol, we did not observe significant changes in antimicrobial use or infection rates in these patients; however, following revision and streamlining of the protocol, we demonstrated a significant reduction in broad-spectrum antimicrobial use for prophylaxis in patients on ECMO without any evidence of a compensatory increase in infection rates. Conclusions Our final protocol significantly reduces broad-spectrum antimicrobial use for prophylaxis in patients on ECMO. We propose a standard antimicrobial prophylaxis regimen for patients on ECMO based on current evidence and our experience. Summary: There are no guidelines for antimicrobial prophylaxis in patients on extracorporeal membrane oxygenation (ECMO). A rational approach employing concepts of antimicrobial stewardship can drive logical antimicrobial selection for prophylaxis in patients on ECMO without adversely impacting outcomes.

Background: Multiple myeloma (MM) is a heterogeneous disease that may be evaluated by a broad array of imaging and laboratory techniques to measure disease activity and predict prognosis. FDG PET/CT has been shown to be predictive of patient outcomes throughout the disease course, with several studies demonstrating that PET/CT is an independent prognostic factor for progression free survival and overall survival (OS). We sought to corroborate these findings by specifically examining the prognostic impact of PET/CT in the post-transplant setting. We retrospectively analyzed PET/CT in MM patients after consolidation therapy with autologous stem cell transplant (ASCT) and correlated these findings with time to progression (TTP) and OS to assess the impact of day 100 PET/CT findings as an independent prognostic factor. Methods: A retrospective cohort study was conducted on 231 myeloma patients who underwent ASCT between 2003-2016 and had a FDG PET/CT exam available for analysis at an average of day 104 post-transplant. We recorded the findings on PET/CT prior to transplant, where available. PET/CT without evidence of active/residual disease (PET-) was defined per IMWG guidelines (disappearance of every area of increased tracer uptake found on preceding PET/CT, or uptake < mediastinal blood pool, or decrease < surrounding normal tissue). PET/CT indicating active disease (PET+) was defined as any abnormal uptake or incompletely resolved uptake from previous exam. A Kaplan-Meier model was used to estimate median TTP and OS and the 2-sided log-rank test to compare groups. TTP and OS were calculated from the date of ASCT to the date of confirmed disease progression or death, respectively. Outcomes were then compared among patients with a PET/CT versus those without a PET/CT post-ASCT to assess for the presence of selection bias. A proportional hazards fit model was used for multivariate analysis. Results: The median length of follow-up for the entire cohort was 49 months (range: 43-58 mo), median TTP was 18.5 months (95% CI; 15.4-21.8), and median OS was 61.5 months (95% CI; 49-75). Among the entire cohort (n=231), 150 (65%) patients had a positive PET/CT exam at day 100 post-ASCT while 81 (35%) had a negative PET exam. There were 195 (84%) patients with a PET/CT exam prior to ASCT available for comparison, of which 161 (85%) were PET+ and 29 (15%) were PET-. Median time between PET/CT exams was 4.1 months (range 1.4-55). Median TTP among PET+ patients near day 100 was 12.4 months vs. 24 months PET- patients (p<.0001, Fig 1, panel A). Median OS in the PET+ group was 46 months compared to 99 months in the PET- group (p<.0001, Fig 1, panel B). Among patients with a prior PET/CT (195, 84%), median TTP was longer in patients with both exams negative compared to those who were day 100 PET- and previously PET+ (42.6 mo vs. 21.1 mo respectively; p<.0001). TTP was shorter in those who were day 100 PET+ and previously PET- compared to those with persistently PET+ on both exams (4.5 vs. 12.3 mo; p<.0001, Figure 2). Since PET/CT was not routinely ordered post ASCT, we also compared the outcomes between patients getting a PET/CT (n=231) and remaining patients undergoing ASCT (n=1764). Among patients with a day 100 PET/CT vs. those without a PET/CT exam, there was a slightly longer median TTP and OS in the group who did not have a post-ASCT PET/CT. Hazard ratios (HR) after adjusting for disease response (CR at day 100 vs. non-CR) were as follows: TTP PET+ HR 1.76 (1.2-2.4; p=0.003), OS PET+ HR 1.8 (1.2-2.6; p=.0016). Conclusions: MM is a heterogeneous disease that relies on different assessments for determining response, activity, and prognosis. Among these, PET/CT has shown promise in predicting prognosis, independent of disease state and conventional prognostic factors. Our study confirms these findings, demonstrating that an abnormal PET/CT near day 100 post-transplant is predictive of shorter TTP and OS. This prognostic significance remained even after adjusting for disease response (CR vs. non-CR), which could be explained by the sometimes patchy distribution of myeloma in the bone marrow, and identification of extramedullary disease by PET/CT. Taken together, these results demonstrate a possible role for incorporating PET/CT in the post-transplant setting as an independent prognostic variable in stratifying disease risk. Disclosures Dingli: Apellis: Consultancy; Janssen: Consultancy; Rigel: Consultancy; Millenium: Consultancy; Karyopharm Therapeutics: Research Funding; Sanofi-Genzyme: Consultancy; Bristol Myers Squibb: Research Funding; Alexion: Consultancy. Gertz:NCI SPORE MM: Research Funding; International Waldenstrom Foundation: Research Funding; Amyloidosis Foundation: Research Funding; Springer Publishing: Patents & Royalties; i3Health: Consultancy; Advisory Board for Proclara: Membership on an entity's Board of Directors or advisory committees; Advisory Board for Pharmacyclics: Membership on an entity's Board of Directors or advisory committees; DAVA oncology: Speakers Bureau; Johnson and Johnson: Speakers Bureau; Celgene: Consultancy; Data Safety Monitoring board from Abbvie: Membership on an entity's Board of Directors or advisory committees; Physicians Education Resource: Consultancy; Medscape: Consultancy, Speakers Bureau; Amgen: Consultancy; Appellis: Consultancy; Annexon: Consultancy; Spectrum: Consultancy, Research Funding; Janssen: Consultancy; Sanofi: Consultancy; Prothena: Consultancy; Alnylam: Consultancy; Ionis/Akcea: Consultancy. Dispenzieri:Janssen: Research Funding; Celgene: Research Funding; Alnylam: Research Funding; Pfizer: Research Funding; Intellia: Research Funding; Takeda: Research Funding. Kapoor:Takeda: Honoraria, Research Funding; Amgen: Research Funding; Sanofi: Consultancy, Research Funding; Janssen: Research Funding; Celgene: Honoraria; Cellectar: Consultancy; GlaxoSmithKline: Research Funding. Lin:Sorrento: Consultancy, Membership on an entity's Board of Directors or advisory committees; Vineti: Consultancy; Novartis: Consultancy; Celgene: Consultancy, Research Funding; Bluebird Bio: Consultancy, Research Funding; Juno: Consultancy; Legend BioTech: Consultancy; Merck: Research Funding; Takeda: Research Funding; Gamida Cells: Consultancy; Janssen: Consultancy, Research Funding; Kite, a Gilead Company: Consultancy, Research Funding. Kumar:Amgen: Consultancy, Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments, Research Funding; Merck: Consultancy, Research Funding; Adaptive Biotechnologies: Consultancy; Janssen Oncology: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Genentech/Roche: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Dr. Reddy's Laboratories: Honoraria; Novartis: Research Funding; Kite Pharma: Consultancy, Research Funding; Karyopharm: Consultancy; Oncopeptides: Consultancy, Other: Independent Review Committee; IRC member; AbbVie: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Takeda: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Cellectar: Other; Tenebio: Other, Research Funding; Sanofi: Research Funding; Celgene/BMS: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Carsgen: Other, Research Funding; Genecentrix: Consultancy; MedImmune: Research Funding; BMS: Consultancy, Research Funding.

Background: The absence of residual monoclonal protein in the serum and urine by IFE using specific antibodies to individual heavy and light chains has been an important part of response assessment and is required for categorizing patients as in complete response. MASS FIX has been shown to be more sensitive in picking up small amounts of monoclonal protein and represents an advancement in the field. Ongoing studies are examining the clinical significance of this increased sensitivity. We designed the following study using clinically obtained test results to examine this question. Patients and methods: The clinical laboratory at Mayo Clinic changed the process from IFE to MASS FIX in July 2018. We identified patients who had sequential testing before and after this date and collected test results from the last IFE prior to the date of transition and the first MASS FIX after the date of transition. Patients were grouped based on the paired results and outcomes compared between groups. Time to next therapy (TTNT) was defined as the time from the first MASS FIX date to the start of next therapy. Survival was estimated by the Kaplan-Meier method and these curves were compared using log rank test. Results: Overall, 739 patients with MM, who had a MASS FIX within 12 months of the IFE were studied; 380 (51%) patients had a negative IFE prior to implementation of MASS FIX. These patients had a MASS FIX test performed at a median of 3.7 (0.03-12) months from the last available IFE. The gap between IFE and MASS FIX was <6 months and < 3 months in 71% and 54% of the patients. Among the patients with a negative IFE, 130 (34%) tested positive on the subsequent MASS FIX. Limiting the analysis to those with a MASS FIX within 6 and 3 months yielded 32% in each group that turned positive from previous negative IFE. The median TTNT from the MASS FIX date was significantly shorter for those who became positive on MASSFIX; median was not reached for either group (P=0.002) (Figure). We then limited the analysis to those patients with a gap of <6 months and <3 months between the tests. The results were consistent: P= 0.012 for those with a gap of < 6 months and P=0.01 for those with a gap < 3 months. Conclusion: The results suggest that the additional sensitivity offered by MASS FIX have clinical significance in patients with MM, given that patients with residual disease identified by MASS FIX have an earlier relapse. The data supports the use of the more sensitive MASS FIX in the laboratory compared to the conventional IFE approaches. The study has the disadvantage that the samples were not tested simultaneously and some of the samples turning positive may reflect an early evidence of relapse, but the relative consistency of the finding irrespective of the gap between the tests argues against that. Ongoing studies are examining MASS FIX on the samples that were called to be negative by IFE initially. Figure Disclosures Murray: The Binding Site: Patents & Royalties: Patent Use of Mass Spec to identify monoclonal proteins licensed to The Binding Site. Dispenzieri:Takeda: Research Funding; Celgene: Research Funding; Janssen: Research Funding; Intellia: Research Funding; Pfizer: Research Funding; Alnylam: Research Funding. Kapoor:Cellectar: Consultancy; Sanofi: Consultancy, Research Funding; Janssen: Research Funding; Celgene: Honoraria; Takeda: Honoraria, Research Funding; GlaxoSmithKline: Research Funding; Amgen: Research Funding. Gertz:Janssen: Other: personal fee; Spectrum: Other: personal fee, Research Funding; Springer Publishing: Patents & Royalties; Abbvie: Other; Appellis: Other: personal fee; Annexon: Other: personal fee; Celgene: Other; Amgen: Other: personal fee; Physicians Education Resource: Other: personal fee; Medscape: Other: personal fee, Speakers Bureau; Research to Practice: Other; Sanofi: Other; Teva: Speakers Bureau; Johnson and Johnson: Speakers Bureau; DAVA oncology: Speakers Bureau; Proclara: Other; Aurora Bio: Other; Prothena: Other: personal fee; Alnylam: Other: personal fee; Ionis/Akcea: Other: personal fee. Dingli:Karyopharm Therapeutics: Research Funding; Bristol Myers Squibb: Research Funding; Rigel: Consultancy; Sanofi-Genzyme: Consultancy; Millenium: Consultancy; Alexion: Consultancy; Janssen: Consultancy; Apellis: Consultancy. Lin:Janssen: Consultancy, Research Funding; Kite, a Gilead Company: Consultancy, Research Funding; Takeda: Research Funding; Gamida Cells: Consultancy; Sorrento: Consultancy, Membership on an entity's Board of Directors or advisory committees; Vineti: Consultancy; Legend BioTech: Consultancy; Merck: Research Funding; Novartis: Consultancy; Celgene: Consultancy, Research Funding; Bluebird Bio: Consultancy, Research Funding; Juno: Consultancy. Kumar:Dr. Reddy's Laboratories: Honoraria; AbbVie: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Carsgen: Other, Research Funding; BMS: Consultancy, Research Funding; Karyopharm: Consultancy; Tenebio: Other, Research Funding; Celgene/BMS: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Adaptive Biotechnologies: Consultancy; Kite Pharma: Consultancy, Research Funding; Sanofi: Research Funding; Takeda: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Janssen Oncology: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Genentech/Roche: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Merck: Consultancy, Research Funding; MedImmune: Research Funding; Cellectar: Other; Genecentrix: Consultancy; Oncopeptides: Consultancy, Other: Independent Review Committee; IRC member; Amgen: Consultancy, Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments, Research Funding; Novartis: Research Funding.

Background: Newly diagnosed patients with AL Amyloidosis are a heterogeneous population, ranging from incidentally found nephrotic syndrome to delayed advanced cardiac disease. For the purposes of trials, patients with the highest-risk disease are often excluded from trial participation. An NT-proBNP of 8500 or higher is the criterion most often used for exclusion from clinical trials due to high rates of early death. It is well documented that overall survival is improving over time, in part due to earlier diagnosis and in part due to more effective therapies. It is our aim to describe outcomes of patients with very high (NT-proBNP >=8500) and advanced stage amyloidosis excluding very high (VH) NT-proBNP. Methods: To address this need, we examined the outcomes of AL patients diagnosed between 1/2012 and 7/2020 and seen at our institution within 90 days of diagnosis. Of the 1290 patients, 291 were seen beyond the 90 day threshold and were thus excluded. Another 170 patients were excluded due to missing biomarkers to calculate stage, leaving 829 patients for our analysis. Thresholds for troponins and BNPs were used according to Muchtar Blood 133(7):2019 to correct for assay used. The vast majority of patients had troponin T measured, and for them the 0.025 mcg/L and the 0.035 mcg/L cut-points were used for the 2012 and 2004 staging systems. A minority of patients did not have troponin T, but rather high sensitivity troponin T (n=129) or troponin I (n=23). For patients with high sensitivity troponin T, cut-points of 41 and 50 ng/L were used, respectively, for the 2012 and 2004 systems, and for patients with troponin I only, a cut-point of 0.1 mcg/L was used for both systems. In the 3 patients with no NT-proBNP but with BNP, 400 and 81 ng/L were used respectively for the 2012 and 2004 systems; otherwise, the 1800 ng/L and 332 ng/L cut-offs were used. A BNP of > 700 ng/L was considered equivalent to NT-proBNP greater than or equal to 8500 ng/L. For the 2012 system, the dFLC of 18 mg/dL was used as a cut-off. Survival estimates were done using the method of Kaplan-Meier, and differences in survival were by determined by Log-Rank. Results: The median age of patients was 65 (range 29, 89), and 65% were male. 148 (17%) of these newly diagnosed patients had a VH (>=8500) NT-proBNP. Patients with VH NT-proBNP were older (67 versus 64 years, p=0.004). Only 4% of the VH NT-proBNP patients received an ASCT in contrast to 34% without VH NT-proBNP. With a median follow-up of 30 months for surviving patients, median OS for VH NT-proBNP patients was 3.3 months in contrast to patients without VH NT-proBNP at 68.4 months (Figure). Breakdown of early death for patients with VH NT-proBNP by stage is shown in Table. Of Mayo 2012 patients staged I, II, III, and IV, the percent of patients with VH NT-proBNP was 0, 3, 20, and 45%. In contrast, for the European modification of the Mayo 2004 system, the percent with VH NT-proBNP by stage was 0, 6, 0, 100 for stages I, II, IIIa, and IIIb, respectively. Among the VH NT-proBNP patients, there was stage discrimination using the Mayo 2012 system (6-month death rates were 17, 45, and 66% for patients with stages II, III, and IV, respectively, p=0.02). In contrast, using the Mayo 2004 system in the patients with VH NT-proBNP, 6-month death rates were 45 and 60% for stage II and IIIb patients, respectively (p= 0.12). Among patients without VH NT-proBNP, rates of death in the first year were 21% including stage I patients whose death rates were well under 10%. Patients without VH NT-proBNP but Mayo 2012 Stage III and IV had 1-year mortalities of 28 and 43% respectively. Using the modified Mayo 2004 system, excluding the VH NT-proBNP 1-year mortality was 19 and 37% for patients with stage II and IIIa, respectively. Discussion: Establishing expected outcomes for the sickest AL amyloidosis patients is a means by which trials can be designed for these patients with an unmet need. Patients with VH NT-proBNP should be considered for specially designed trials, and patients without VH NT-proBNP and advanced stage should be included in trials for newly diagnosed patients regardless of stage as long as there is appropriate stratification. Disclosures Dispenzieri: Janssen: Research Funding; Pfizer: Research Funding; Intellia: Research Funding; Alnylam: Research Funding; Celgene: Research Funding; Takeda: Research Funding. Kumar:AbbVie: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Tenebio: Other, Research Funding; BMS: Consultancy, Research Funding; Sanofi: Research Funding; Carsgen: Other, Research Funding; Amgen: Consultancy, Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments, Research Funding; Oncopeptides: Consultancy, Other: Independent Review Committee; IRC member; Celgene/BMS: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Merck: Consultancy, Research Funding; Takeda: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Janssen Oncology: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Adaptive Biotechnologies: Consultancy; Dr. Reddy's Laboratories: Honoraria; Novartis: Research Funding; MedImmune: Research Funding; Genecentrix: Consultancy; Kite Pharma: Consultancy, Research Funding; Cellectar: Other; Karyopharm: Consultancy; Genentech/Roche: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments. Dingli:Karyopharm Therapeutics: Research Funding; Bristol Myers Squibb: Research Funding; Millenium: Consultancy; Janssen: Consultancy; Alexion: Consultancy; Rigel: Consultancy; Apellis: Consultancy; Sanofi-Genzyme: Consultancy. Kapoor:Celgene: Honoraria; Cellectar: Consultancy; Janssen: Research Funding; Sanofi: Consultancy, Research Funding; Amgen: Research Funding; Takeda: Honoraria, Research Funding; GlaxoSmithKline: Research Funding. Lin:Janssen: Consultancy, Research Funding; Kite, a Gilead Company: Consultancy, Research Funding; Novartis: Consultancy; Celgene: Consultancy, Research Funding; Bluebird Bio: Consultancy, Research Funding; Juno: Consultancy; Legend BioTech: Consultancy; Merck: Research Funding; Takeda: Research Funding; Gamida Cells: Consultancy; Sorrento: Consultancy, Membership on an entity's Board of Directors or advisory committees; Vineti: Consultancy. Gertz:Springer Publishing: Patents & Royalties; Amyloidosis Foundation: Research Funding; International Waldenstrom Foundation: Research Funding; NCI SPORE MM: Research Funding; Ionis/Akcea: Consultancy; Alnylam: Consultancy; Prothena: Consultancy; Sanofi: Consultancy; Janssen: Consultancy; Spectrum: Consultancy, Research Funding; Annexon: Consultancy; Appellis: Consultancy; Amgen: Consultancy; Medscape: Consultancy, Speakers Bureau; Physicians Education Resource: Consultancy; Data Safety Monitoring board from Abbvie: Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy; Johnson and Johnson: Speakers Bureau; DAVA oncology: Speakers Bureau; Advisory Board for Pharmacyclics: Membership on an entity's Board of Directors or advisory committees; Advisory Board for Proclara: Membership on an entity's Board of Directors or advisory committees; i3Health: Consultancy.

Abstract The first test for recognition of monoclonal gammopathies should be serum protein electrophoresis with high-resolution agarose gel. Serum protein electrophoresis should be performed whenever multiple myeloma, Waldenström’s macroglobulinemia, primary amyloidosis, or a related disorder is suspected. Immunofixation is critical for the differentiation of a monoclonal from a polyclonal increase in immunoglobulins. Quantitation of immunoglobulins should be performed with a rate nephelometer. The viscosity of serum should be measured if the patient has signs or symptoms of hyperviscosity syndrome. A 24-hour urine specimen should be obtained for determination of the total amount of protein excreted each day. Immunofixation of the urine should be performed on every patient who has an M-protein level greater than 1.5 g/dL (15 g/L) in the serum or in whom multiple myeloma, Waldenström’s macroglobulinemia, primary amyloidosis, or a related disorder is suspected.

Abstract This guideline provides the recommendations of an expert panel for the clinical and laboratory evaluation of patients suspected of having a clinical condition that produces a monoclonal protein in serum or urine. The recommendations describe the clinical conditions in which a monoclonal protein should be sought, the optimal sequence of testing to diagnose and monitor these patients, and the most effective laboratory procedures.

Severe acute respiratory distress syndrome (ARDS) unresponsive to conventional intensive care unit (ICU) management is an accepted indication for venovenous extracorporeal membrane oxygenation (V-V ECMO) support. The frequency with which patients with coronavirus disease 2019 (COVID-19) pneumonia are selected for V-V ECMO has not been described. This was a cohort study including all patients placed on either V-V ECMO or venoarteriovenous ECMO at the four adult ECMO Centers of Excellence. Primary outcomes evaluated were survival to decannulation from the ECMO circuit, survival to discharge, and 60-day survival. Secondary outcomes were hospital length of stay (LOS), ICU LOS, length of ECMO cannulation, and length of intubation. During the study period, which corresponded to the first surge in COVID-19 hospitalizations in Minnesota, 35 patients with ARDS were selected for V-V ECMO support out of 1,849 adult ICU patients with COVID-19 infection in the state (1.9% incidence; 95% CI, 1.3–2.6%). This represents 46 (95% CI, 34–61) expected V-V ECMO patients per 100,000 confirmed positive cases of COVID-19. Twenty-six of the 35 patients (74.3%) supported with V-V ECMO survived to 60-day post-ECMO decannulation. Recent studies have demonstrated ongoing success rescuing patients with severe ARDS in COVID-19 infection. Our data add to the support of ECMO and the consideration for encouraging cooperation among regional ECMO centers to ensure access to this highest level of care. Finally, by evaluating all the patients of a single region, we estimate overall need for this resource intensive intervention based on the overall number of COVID-19 cases and ICU admissions.

Variables in cardiology fellowship applications have not been objectively analyzed against applicants' subsequent clinical performance. We investigated possible correlations in a retrospective cohort study of 65 cardiology fellows at the Mayo Clinic (Rochester, Minn) who began 2 years of clinical training from July 2007 through July 2013. Application variables included the strength of comparative statements in recommendation letters and the authors' academic ranks, membership status in the Alpha Omega Alpha Honor Medical Society, awards earned, volunteer activities, United States Medical Licensing Examination (USMLE) scores, advanced degrees, publications, and completion of a residency program ranked in the top 6 in the United States. The outcome was clinical performance as measured by a mean of faculty evaluation scores during clinical training. The overall mean evaluation score was 4.07 ± 0.18 (scale, 1–5). After multivariable analysis, evaluation scores were associated with Alpha Omega Alpha designation (β=0.13; 95% CI, 0.01–0.25; P=0.03), residency program reputation (β=0.13; 95% CI, 0.05–0.21; P=0.004), and strength of comparative statements in recommendation letters (β=0.08; 95% CI, 0.01–0.15; P=0.02), particularly in letters from residency program directors (β=0.05; 95% CI, 0.01–0.08; P=0.009). Objective factors to consider in the cardiology fellowship application include Alpha Omega Alpha membership, residency program reputation, and comparative statements from residency program directors.

AbstractThree sets of criteria (International Society of Amyloidosis [ISA], Palladini and Kastritis) were independently developed for staging, progression and response criteria to predict renal survival in patients with AL amyloidosis. We evaluated these criteria using a cohort of 495 newly diagnosed AL amyloidosis patients with renal involvement using time to event competing risk analysis at baseline, 3, 6 and 12 months after treatment. Only Palladini and Kastritis had a staging system and both predicted a higher risk of end stage renal disease (ESRD) in the stage III vs stage I patients but only the Palladini model was predictive for stage II patients. At 3 months, risk of ESRD was significantly higher for Palladini and ISA renal progression (hazard ratio [HR] 2.8 [95% CI: 1.5–5.3, p = .001] and 2.5 [CI: 1.4–4.6, p = .004, respectively]), but renal response was not significantly protective; conversely, the risk of ESRD was not significantly higher for the Kastritis renal progression, but was significantly protective for the Kastritis renal responders (HR 0.38 [95% CI: 0.17–0.84], p = .017). Both progression and response with ISA, Palladini and Kastritis criteria were predictive of ESRD at 6 months and 12 months. While the Palladini staging criteria at baseline, and the ISA and Palladini criteria for progression at 3 months performed better than the Kastritis criteria at baseline and 3 months post‐treatment, the Kastritis criteria performed better for response 3 months after treatment. All three sets of criteria performed well at and after 6 months post‐treatment. These differences are important when choosing endpoints for clinical trials.