Citations

Black race and Hispanic ethnicity are associated with higher mortality in severe combined immunodeficiency (SCID) following hematopoietic cell transplantation (HCT), though mechanisms remain unclear. We evaluated 796 children with SCID who received nonsibling HCT between 1982 and 2020 using data from the Primary Immune Deficiency Treatment Consortium. Overall survival for Black (aHR 2.47, 95%CI 1.64, 3.71) and Asian/Pacific Islander patients (aHR 1.82, 95%CI 1.00, 3.30) was significantly lower compared with non-Hispanic White patients, while Hispanic patients had lower event-free survival (aHR 1.83, 95%CI 1.27, 2.63) compared with non-Hispanic White patients. Even after adjusting for age and infection, Black patients with SCID had more than twofold hazard of death compared with non-Hispanic White patients. NBS was associated with earlier diagnosis, reduced infection at HCT, and elimination of survival disparities between Black and non-Hispanic White patients. These findings suggest that universal, system-level interventions such as NBS can mitigate disparities in outcomes for children with SCID.

Cercospora leaf spot (CLS) is a destructive disease of sugar beet (Beta vulgaris ssp. vulgaris L.) for which resistance conferred by the gene BvCR4 has been introgressed from sea beet (B. vulgaris ssp. maritima). BvCR4-mediated resistance has been broadly deployed to manage CLS globally in sugar beet; however, continuous implementation exerts strong selection pressure, increasing the risk of disease outbreaks due to resistance-breaking C. beticola populations. This study aimed to identify BvCR4 variants in public B. vulgaris spp. germplasm to assess their genetic and structural diversity. Polymerase chain reaction screening of 589 public B. vulgaris spp. germplasm detected BvCR4 homologs in 32 accessions with diverse responses to CLS including historically relevant sugar beet lines represented in breeding programs and Mediterranean sea beet populations of diverse genetic backgrounds. Analysis of the genomic sequences revealed higher diversity in sea beet compared to sugar beet. Additionally, population genetic analysis indicated that BvCR4 homologs in sugar beet likely originated from sea beet populations in Italy and Greece. We identified historical cultivated materials carrying full proteins encoded by BvCR4 alleles and delineated geographic regions where sea beet populations harbor BvCR4 homologs that may be useful in breeding programs. Structural variation was largely circumscribed within leucine-rich repeat domains, although CLS resistance phenotyping was not associated with specific polymorphisms, suggesting BvCR4-mediated resistance may rely on interactions with other co-receptors. This study provides resources for sugar beet improvement by enabling the identification of BvCR4 homologs in diverse germplasm and disclosing materials with potentially novel resistance.

Primary care is a language-intensive environment where clinicians frequently synthesize, document, and communicate large amounts of information. Given the amount of information in primary care, large language models (LLMs) have emerged as tools to support primary care clinician workflows, aiming to reduce administrative burden and augment patient care. LLMs are artificial intelligence tools that can generate text and assist with chart summarization, message drafting, and clinical decision support. However, because LLMs are probabilistic, identical inputs may yield inconsistent responses. The LLMs output can be significantly improved through prompt engineering. Prompt engineering is the intentional design of text entered into the LLM to help produce better LLM results. Prompting is best approached as an iterative process where a clinician defines the task, the LLM generates output, and the clinician critically reviews and refines the results. Low-quality prompts are often vague and produce generic or misleading responses. High-quality prompts are specific, context-rich, and well-structured. Using structured prompting frameworks can improve the LLMs response. Including core elements, such as the LLMs role, the clinical context, the requested task, and the desired output formatting, can help improve the LLMs response by providing situational background and framing response formatting. Additional frameworks, such as Ask-Context-Expectation and PICO+O, can be utilized for specific patient circumstances and cases. However, despite their promise, LLMs have important limitations. They may generate inaccurate or hallucinated information and produce inconsistent results. Given these limitations, LLMs should not be viewed as knowledge authorities but rather as cognitive assistants. Thoughtful prompt design can help reduce these limitations and improve response accuracy, always keeping in mind that LLMs should not replace human judgment or clinical reasoning. As LLMs continue to be integrated into primary care, prompt engineering will become an increasingly important clinical skill. Careful prompt design and critical appraisal of LLM responses will be key to maintaining excellent patient care in the AI era.

Interest in using gene therapy to treat osteoarthritis (OA) is growing and a number of clinical trials have been initiated. This commentary identifies three intersecting areas that need to be addressed for the field to move forward expeditiously. The first relates to lowering the cost of manufacturing clinical grade viral vectors, addressing various aspects of their deployment, and overcoming immune barriers to dosing and re-dosing. The second area requires an improved understanding of the pathophysiology of OA, including its stratification by endotype and phenotype. Coupled to the development of reliable biomarkers, this will enable the creation of personalized gene therapies, facilitate patient selection, and aid the identification of additional molecular targets. Moreover, progress in the early diagnosis of OA will enable administration of gene therapeutics at a stage when they are most likely to be successful. Finally, important issues with regard to financing and regulation are discussed. Top line data from two pivotal Phase III clinical trials are expected to be released this year. The findings from these trials will exercise considerable influence on the future development of the field.

ABSTRACT Patients requiring permanent pacing after tricuspid valve intervention present challenges due to the need to cross tricuspid valve prostheses. We report three cases of successful dual coronary sinus (CS) lead implantation for biventricular pacing following a range of tricuspid interventions—surgical tricuspid annuloplasty, transcatheter edge‐to‐edge repair, and transcatheter tricuspid valve replacement. The approach avoided tricuspid valve traversal, was technically feasible and resulted in satisfactory pacing performance without procedural complications. Dual CS lead configurations were individualized based on CS anatomy and pacing characteristics. The degree of QRS narrowing achieved varied according to lead location and ventricular activation patterns, highlighting the importance of individualized lead placement strategies and device programming. Dual CS lead pacing may represent a viable alternative for biventricular pacing in selected patients with prior tricuspid valve interventions. Larger studies are needed to evaluate long‐term outcomes and define the optimal role of this approach among available pacing strategies in this patient population.

Study Design. Post hoc analysis of prospectively-collected data. Objective. To identify factors predicting the most (and least) satisfaction following surgery for cervical spondylotic myelopathy (CSM). Summary of Background Data. Patient satisfaction affects long-term outcomes after surgery but the preoperative factors that influence postoperative satisfaction have not been well studied in patients with CSM. Methods. We conducted a post hoc analysis of prospectively-collected data from the Quality Outcomes Database (QOD) CSM registry cohort. Baseline and surgical characteristics were compared for patients with CSM reporting the most [North American Spine Society Satisfaction Score (NASS) 1] and least (NASS 4) satisfaction 24 months postoperatively. A multivariable logistic regression model was constructed using backward stepwise elimination to determine significant predictors of most versus least satisfaction. Twenty-four-month patient-reported outcomes (PROs) were compared. Results. Overall, 1141 patients were prospectively enrolled with 948 (83.1%) reaching 24-month follow-up. Of these, 699 met prespecified inclusion criteria: 610 (87.3%) were most satisfied and 89 (12.7%) were least satisfied. Though there were mean improvements in all 24-month PROs for the most satisfied cohort ( P <0.001), there were no significant improvements in 24-month PROs for the least satisfied cohort ( P >0.05). Using multivariable logistic regression modeling, a preoperative symptom of upper extremity weakness (OR=2.5, P =0.003), subjective myelopathy (OR=2.0, P =0.04), absence of numbness complaints (OR=2.2, P =0.003), symptom duration under 12 months (OR=1.6, P =0.047), Caucasian race (OR=2.3, P =0.001), participation in activities outside of the home (OR=2.0, P =0.04), anterior approach (OR=2.3, P <0.001), and higher baseline quality of life (OR=4.0, P =0.01) were predictive of the most satisfaction. Conclusion. Compared with the least satisfied, those most satisfied following surgery for CSM more often had a preoperative symptom of arm weakness, subjective myelopathy, the absence of numbness complaints, symptom duration under 12 months, higher baseline quality of life, and participation in activities outside of the home. Compared with a posterior approach, an anterior approach was associated with the most satisfaction. Taken together, early surgical treatment--before myelopathic symptoms significantly impact one's quality of life--may be considered to optimize patient satisfaction following CSM surgery.

Patients with plasma cell leukemia (PCL) are generally excluded from pivotal T-cell redirecting bispecific antibody (BsAb) trials. We evaluated real-world outcomes in a multicenter retrospective study of 122 patients with primary or secondary PCL across 15 academic centers, categorized as 'active' (≥5% circulating plasma cells within 30 days of BsAb initiation) or 'historical'. In a heavily pretreated population, patients received teclistamab (37%), elranatamab (11%), talquetamab as a line of therapy (Tal LOT, 42%), or talquetamab as bridging therapy to CAR-T (Tal Bridge, 11%). Cytokine release syndrome (CRS) was grade 1-2 in 56% and grade 3-4 in 4%, whereas neurotoxicity was grade 1-2 in 16% and grade 3-4 in 5%. Among 110 evaluable patients, the overall response rate (ORR) was 55%, including 61% with Tal LOT, 58% with Tal Bridge, 46% with elranatamab, and 33% with teclistamab. With a median follow-up of 8.3 months, talquetamab demonstrated superior survival. Tal LOT showed a median progression-free survival (mPFS) of 5.5 months and a median overall survival (mOS) of 11.5 months, and both were unreached in the Tal Bridge cohort. In contrast, teclistamab and elranatamab showed a mPFS of 1.2 and 1.6 months and mOS of 8.1 and 3.6 months, respectively (P=0.007, P=0.023). In active PCL, Tal LOT achieved mPFS/mOS of 6.9/12.2 months versus 0.7/1.4 months with teclistamab and 1.0/3.1 months with elranatamab, respectively (P&lt;0.001, P=0.002). Multivariable analysis associated active PCL with worse survival and Tal LOT with improved outcomes. BsAbs were safe in PCL, with talquetamab showing superior outcomes compared with BCMA-directed BsAbs.

PURPOSE Incorporation of structured data elements within the electronic health record generates real-time data for many potential uses. However, this requires a change in documentation practices, which may increase documentation effort. The best strategies to support structured documentation interventions have not been thoroughly investigated. Herein, we report the results of extending a data capture tool across multiple disease sites and practice locations. METHODS A note-based data capture tool was developed to collect five data elements using minimum common oncology data elements language. Soft-stop close visit validation (CVV), offloading of data entry tasks to allied health staff, group education, individualized e-mails, and one-on-one assistance were used to support utilization. Baseline and follow-up surveys were collected. For each provider, we compared data capture in the 6 months before and after their CVV go-live. RESULTS Forty-five providers participated (31 physicians, 14 nurse pracationers and physician assistants [NPPAs]), resulting in 23,274 encounters pre-CVV go-live and 23,146 post-CVV go-live visits. Median percentage of all data elements captured increased from 69.5% to 82.6% across all providers. The effect of CVV was immediate and sustained. When surveyed, most respondents agreed with the value propositions of understanding practice population, outcomes, selecting trials to open, and identifying patients for trial enrollment. Most respondents (15/20, 75%) felt the soft stop was a helpful reminder. CONCLUSION Structured data can be successfully collected in provider notes with >80% data capture. Personalized assistance incorporating the structured data elements into users' preexisting templates and soft-stop CVV, along with monitoring the results of implementation and personalized follow-up, was used to support the structured data capture intervention.

Dynamic gadopiclenol-enhanced nodal and pedal MR lymphangiography was safe, with no adverse events, and feasible for imaging peripheral and central conducting lymphatic anatomy.