Citations

OBJECTIVES: Cardiac arrests remain a leading cause of death worldwide. Most patients have nonshockable electrocardiographic presentations (asystole/pulseless electrical activity). Despite well-performed basic and advanced cardiopulmonary resuscitation (CPR) interventions, patients with these presentations have always faced unlikely chances of survival. The primary objective was to determine if, in addition to conventional CPR (C-CPR), expeditious application of noninvasive circulation-enhancing adjuncts, and then gradual elevation of head and thorax, would be associated with higher likelihoods of survival following out-of-hospital cardiac arrest (OHCA) with nonshockable presentations. DESIGN: Using a prospective observational study design (ClinicalTrials.gov NCT05588024), patient data from the national registry of emergency medical services (EMS) agencies deploying the CPR-enhancing adjuncts and automated head/thorax-up positioning (AHUP-CPR) were compared with counterpart reference control patient data derived from the two National Institutes of Health clinical trials that closely monitored quality CPR performance. Beyond unadjusted comparisons, propensity score matching and matching of time to EMS-initiated CPR (TCPR) were used to assemble cohorts with corresponding best-fit distributions of the well-established characteristics associated with OHCA outcomes. SETTING: North American 9-1-1 EMS agencies. PATIENTS: Adult nontraumatic OHCA patients receiving 9-1-1 responses. INTERVENTIONS: In addition to C-CPR, study patients received the CPR adjuncts and AHUP (all U.S. Food and Drug Administration-cleared). MEASUREMENTS AND MAIN RESULTS: The median TCPR for both AHUP-CPR and C-CPR groups was 8 minutes. Median time to AHUP initiation was 11 minutes. Combining all patients irrespective of lengthier response intervals, the collective unadjusted likelihood of AHUP-CPR group survival to hospital discharge was 7.4% (28/380) vs. 3.1% (58/1,852) for C-CPR (odds ratio [OR], 2.46 [95% CI, 1.55–3.92]) and, after propensity score matching, 7.6% (27/353) vs. 2.8% (10/353) (OR, 2.84 [95% CI, 1.35–5.96]). Faster AHUP-CPR application markedly amplified odds of survival and neurologically favorable survival. CONCLUSIONS: These findings indicate that, compared with C-CPR, there are strong associations between rapid AHUP-CPR treatment and greater likelihood of patient survival, as well as survival with good neurological function, in cases of nonshockable OHCA.

Radiation therapy (RT) is an essential part of the multidisciplinary treatment of pediatric cancer. Over the past five decades, significant advances have been made in the delivery of RT, with better dose delivery to disease targets while minimizing exposure to nearby organs at risk. These advances have led to improved treatment outcomes, increased survival, and reduced treatment-related toxicities. Advanced treatment techniques, however, require significant investment in infrastructural and personnel resources. This review documents what is currently available regarding expertise and infrastructure for pediatric radiation oncology practice in Nigeria. It was performed to serve as a foundation for the creation and design of tailored solutions (initiatives and policies) to increase pediatric radiation availability, accessibility, and equity in Nigeria and ultimately improve pediatric cancer treatment outcomes in the region.

PURPOSE Outcomes for patients with newly diagnosed multiple myeloma (NDMM) are heterogenous, with overall survival (OS) ranging from months to over 10 years. METHODS To decipher and predict the molecular and clinical heterogeneity of NDMM, we assembled a series of 1,933 patients with available clinical, genomic, and therapeutic data. RESULTS Leveraging a comprehensive catalog of genomic drivers, we identified 12 groups, expanding on previous gene expression–based molecular classifications. To build a model predicting individualized risk in NDMM (IRMMa), we integrated clinical, genomic, and treatment variables. To correct for time-dependent variables, including high-dose melphalan followed by autologous stem-cell transplantation (HDM-ASCT), and maintenance therapy, a multi-state model was designed. The IRMMa model accuracy was significantly higher than all comparator prognostic models, with a c-index for OS of 0.726, compared with International Staging System (ISS; 0.61), revised-ISS (0.572), and R2-ISS (0.625). Integral to model accuracy was 20 genomic features, including 1q21 gain/amp, del 1p, TP53 loss, NSD2 translocations, APOBEC mutational signatures, and copy-number signatures (reflecting the complex structural variant chromothripsis). IRMMa accuracy and superiority compared with other prognostic models were validated on 256 patients enrolled in the GMMG-HD6 (ClinicalTrials.gov identifier: NCT02495922 ) clinical trial. Individualized patient risks were significantly affected across the 12 genomic groups by different treatment strategies (ie, treatment variance), which was used to identify patients for whom HDM-ASCT is particularly effective versus patients for whom the impact is limited. CONCLUSION Integrating clinical, demographic, genomic, and therapeutic data, to our knowledge, we have developed the first individualized risk-prediction model enabling personally tailored therapeutic decisions for patients with NDMM.

AbstractBackgroundChronic traumatic encephalopathy (CTE) is a neurodegenerative disease thought to be caused, in part, by repetitive head impact (RHI) exposure and characterized by phosphorylated tau deposition with varying patterns in the cerebral cortex. Flortaucipir tau PET data from the DIAGNOSE CTE Research Project was examined to investigate tau PET patterns and its relation to RHI exposure in former professional and college American football players.MethodIn this study, 218 DIAGNOSE CTE participants, ages 45‐74, with flortaucipir PET were included; 104 were former National Football League players (PRO), 58 were former college football players (COL), and 56 had no history of contact sports, other exposure to RHI, or traumatic brain injury (UE). Regional flortaucipir uptake was quantified using established procedures for three previously defined statistical regions (superior frontal, left parietal, and medial temporal) and compared across the three groups. Association analyses were also performed to examine the relationship between flortaucipir uptake and exposure to RHI using the cumulative head impact index for linear acceleration g‐force (CHII‐G). The potential clinical utility of flortaucipir PET for CTE was also investigated by examining its ability to differentiate participants meeting criteria for traumatic encephalopathy syndrome (TES) and probable or possible level of certainty for CTE pathology from those who do not meet those criteria.ResultSignificantly higher flortaucipir uptake was observed in former football players than in participants without RHI exposure, controlling for age and race for the superior frontal region (Fig. 1A), left parietal, and medial temporal regions. Association between regional flortaucipir uptake and CHII‐G was only observed in the superior frontal region in former players (PRO+COL) 60 years and older (Fig. 1B) and no association was observed in the full PRO+COL group. Flortaucipir PET was not able to differentiate TES groups in former football players (Fig. 1C).ConclusionElevated flortaucipir uptake was observed in former American football players to a group of unexposed men. The association between flortaucipir uptake and exposure to RHI may require a long latent period to manifest. Further investigation of more sensitive tau PET tracers and quantification techniques is warranted to better characterize CTE related tau pathology.

AbstractBackgroundRepetitive head impact (RHI) exposure from the routine play of American football increases the risk of later‐life cognitive impairment and dementia from the neurodegenerative disease, chronic traumatic encephalopathy (CTE). Although neuropathological studies of CTE have found comorbid neurodegenerative and other pathologies, neuritic Aβ plaques are infrequent, particularly in early stages. However, amyloid PET imaging has not been fully characterized in cognitively impaired former American football players.MethodIn this cross‐sectional, observational cohort study from the DIAGNOSE CTE Research Project, florbetapir PET mean cortical standard uptake value ratios (SUVR) and positivity (defined by average SUVR >1.10, indicative of moderate‐to‐frequent neuritic Aβ plaques), were analyzed in 119 former professional (PRO) National Football League players, 60 former college football players (COL), and 58 men unexposed (UE) to RHI who were cognitively asymptomatic. Former players were categorized into one of four diagnostic groups: cognitively normal (CN), subjective memory complaints (SMC), mild cognitive impairment (MCI), and dementia (DEM). All participants were 45‐74 yo. Multivariable linear and logistic regressions were conducted, with race, education, age, and APOE4 genotype included as covariates. A priori power calculations demonstrated adequate power to detect significant findingsResultNo differences between the three exposure groups in average florbetapir SUVR or proportion of elevated florbetapir uptake were found. Pairwise group comparisons resulted in no differences in average SUVR between PRO and COL (‐0.01, 95% CI [‐0.033, 0.025], p = 0.95), PRO and UE (0.02, 95% CI [‐0.010, 0.029], p = 0.41), and COL and UE (0.02, 95% CI [0.0004, 0.039], p = 0.36). Analysis of covariance resulted in no differences among diagnostic groups (F = 0.94, p = 0.43). Neither years of playing football nor measures of cognition and daily functioning showed significant associations with florbetapir SUVR.ConclusionFormer professional and college American football players with cognitive impairment and dementia did not have elevated florbetapir amyloid PET compared to a group of men without RHI exposure. Their rates of florbetapir positivity in the football players were lower than expected for a group of men this age. These findings suggest that cognitive impairment in former elite football players may not be due to Alzheimer’s disease pathology.

AbstractINTRODUCTIONTau is a key pathology in chronic traumatic encephalopathy (CTE). Here, we report our findings in tau positron emission tomography (PET) measurements from the DIAGNOSE CTE Research Project.METHODWe compare flortaucipir PET measures from 104 former professional players (PRO), 58 former college football players (COL), and 56 same‐age men without exposure to repetitive head impacts (RHI) or traumatic brain injury (unexposed [UE]); characterize their associations with RHI exposure; and compare players who did or did not meet diagnostic criteria for traumatic encephalopathy syndrome (TES).RESULTSSignificantly elevated flortaucipir uptake was observed in former football players (PRO+COL) in prespecified regions (p < 0.05). Association between regional flortaucipir uptake and estimated cumulative head impact exposure was only observed in the superior frontal region in former players over 60 years old. Flortaucipir PET was not able to differentiate TES groups.DISCUSSIONAdditional studies are needed to further understand tau pathology in CTE and other individuals with a history of RHI.

Abstract Objectives VEXAS syndrome is an adult-onset autoinflammatory disease caused by a somatic pathogenic mutation in the UBA1 (ubiquitin-like modifier activating enzyme 1) gene. Patients present with rheumatologic manifestations and cytopenias and may have an increased predisposition to myelodysplastic syndrome (MDS) and plasma cell neoplasms. Prior studies have reported on the peripheral blood and bone marrow findings in patients with VEXAS syndrome. Due to the protean clinical presentation and lack of specificity of morphologic features (eg, vacuoles in early erythroid and granulocytic precursors), an optimal screening methodology to identify these patients in a timely fashion is desirable. Methods To further evaluate and describe the salient diagnostic morphologic features in VEXAS syndrome, we carried out a comprehensive study of the largest single-institution cohort to date. Diagnostic and follow-up bone marrow biopsy specimens from 52 male patients with molecularly identified VEXAS syndrome underwent central review. Results Cytopenias were common in all cases, primarily macrocytic anemia, monocytopenia, and thrombocytopenia. Bone marrow aspirate and biopsy were often hypercellular, with an increased myeloid/erythroid ratio, granulocytic hyperplasia with left shift, erythroid left shift, and megakaryocyte hyperplasia, which exhibited a range of striking morphologic findings. Distinctly vacuolated myeloid and erythroid precursors were seen in more than 95% of cases. Conclusions Our data reveal potential novel diagnostic features, such as a high incidence of monocytopenia and distinct patterns of atypical megakaryopoiesis, that appear different from dysmegakaryopoiesis typically associated with MDS. In our experience, those findings are suggestive of VEXAS, in the appropriate clinical context.

Abstract Blood is the most commonly used body fluid for extracellular vesicle (EV) research. The composition of a blood sample and its derivatives (i.e., plasma and serum) are not only donor‐dependent but also influenced by collection and preparation protocols. Since there are hundreds of pre‐analytical protocols and over forty variables, the development of standard operating procedures for EV research is very challenging. To improve the reproducibility of blood EV research, the International Society for Extracellular Vesicles (ISEV) Blood EV Task Force proposes standardized reporting of (i) the applied blood collection and preparation protocol and (ii) the quality of the prepared plasma and serum samples. Gathering detailed information will provide insight into the performance of the protocols and more effectively identify potential confounders in the prepared plasma and serum samples. To collect this information, the ISEV Blood EV Task Force created the Minimal Information for Blood EV research (MIBlood‐EV), a tool to record and report information about pre‐analytical protocols used for plasma and serum preparation as well as assays used to assess the quality of these preparations. This tool does not require modifications of established local pre‐analytical protocols and can be easily implemented to enhance existing databases thereby enabling evidence‐based optimization of pre‐analytical protocols through meta‐analysis. Taken together, insight into the quality of prepared plasma and serum samples will (i) improve the quality of biobanks for EV research, (ii) guide the exchange of plasma and serum samples between biobanks and laboratories, (iii) facilitate inter‐laboratory comparative EV studies, and (iv) improve the peer review process.