Citations

Abstract Background IDH-mutant astrocytomas are classified as WHO grade 4 in the presence of conventional high-grade histologic features and/or homozygous CDKN2A/B deletion in the 5th edition of the WHO Classification of Central Nervous System Tumour guidelines. However, work over the past decade has indicated a number of other molecular alterations that warrant consideration as potential prognostic markers. Methods We used univariate Kaplan-Meier and multivariate Cox proportional hazards regression analysis to evaluate the prognostic effects of homozygous CDKN2A/B deletion, CDK4 amplification, CCND2 amplification, PDGFRA amplification/mutation, PIK3R1 mutation, PIK3CA mutation, MYCN amplification, EGFR amplification/mutation, TERT promoter mutation, and grade 4 histologic features in two independent cohorts of WHO grade 2-4 IDH-mutant astrocytoma (n = 840 and n = 367). Results The presence of CDK4 amplification, CCND2 amplification, PDGFRA alteration, PIK3R1 mutation, MYCN amplification, and EGFR alteration were each associated with reduced overall survival compared to WHO grade 2/3 astrocytomas without these molecular features. 17.7% (148/837) of otherwise grade 2/3 astrocytomas had one or more of these molecular criteria, with resulting intermediate clinical outcome in terms of overall survival (median survival of 67.3-82.0 months) compared to grade 2/3 astrocytomas without these molecular features (median survival of 135.0-140.7 months) and grade 4 astrocytomas (median survival of 35.3-45.0 months). Conclusions The presence of CDK4, CCND2, PDGFRA, PIK3R1, MYCN, and EGFR alterations result in an intermediate patient survival in IDH-mutant astrocytoma. Adding these molecular alterations should be considered in future diagnostic classification systems to improve stratification of high-risk patients.

Abstract Background Artificial intelligence (AI)–based, mammography breast cancer risk prediction models show improved discriminatory accuracy relative to clinical risk models. However, data on their calibration are limited. This study compared model performance of 3 clinical breast cancer risk models: Gail, Tyrer–Cuzick v8, and Breast Cancer Surveillance Consortium v3 with the MIRAI AI-risk model. Methods Digital mammograms were ascertained from a screening mammography cohort of 12 308 women within the Mayo Clinic Biobank with 250 incident breast cancers (176 invasive) within 5 years. We predicted 5-year breast cancer risk, estimated discriminatory accuracy (C-index), and calibration (observed-to-expected ratio) of both overall and invasive breast cancer and compared estimates using bootstrapping approaches. Results MIRAI demonstrated similar or improved discriminatory accuracy of overall breast cancer (C-index = 0.71, 95% confidence interval [CI] = 0.68 to 0.74) and invasive breast cancer (C-index = 0.71, 95% CI = 0.67 to 0.75) compared with clinical models (overall breast cancer: C-index = 0.59-0.68; invasive breast cancer: C-index = 0.60-0.68). MIRAI’s calibration for risk of overall breast cancer (observed-to-expected ratio = 0.96, 95% CI = 0.85 to 1.08) was improved compared with Gail (observed-to-expected ratio = 1.22, 95% CI = 1.07 to 1.38) and Breast Cancer Surveillance Consortium (observed-to-expected ratio = 1.38, 95% CI = 1.22 to 1.56) but similar to TC with volumetric percent density and polygenic risk score (observed-to-expected ratio = 0.99, 95% CI = 0.87 to 1.13). However, for low-risk women (approximately 50%), MIRAI overestimated risk of overall breast cancer. MIRAI also overestimated risk of invasive breast cancer across the risk spectrum (observed-to-expected ratio = 0.68, 95% CI = 0.58 to 0.78), whereas clinical models had good calibration (observed-to-expected ratio = 0.86–0.99). Conclusion MIRAI demonstrated stronger discriminatory accuracy than clinical models for 5-year overall and invasive breast cancer risk prediction but overestimated risk for both breast cancer endpoints. AI-based risk models should consider discriminatory accuracy and calibration for invasive cancer before implementation.

OBJECTIVE: A definition of refractory septic shock is necessary to guide diagnosis, management, prognostication, research, and future guidelines for this most severe form of the disease. We sought to achieve consensus on clinical criteria that would be used to define refractory septic shock. DESIGN: Review of literature, expert panel position statements, and Delphi rounds with an international expert group. SETTING: Consensus was defined as having at least 75% of panellists in agreement or disagreement on the three highest or lowest levels of a 7-point Likert scale or based on responses to single- or multiple-choice questions, respectively. SUBJECTS: A panel of multinational, multiprofessional and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (57 invitations and 56 participants). MEASUREMENTS AND MAIN RESULTS: A five-round Delphi process was conducted for consensus and stability. The steering committee proposed 34 statements, and five of them were rejected by panel experts after round 2. Among 29 statements selected from eight domains, consensus was reached for 13. The panel agreed on the need for a comprehensive consensus set of clinical criteria for refractory septic shock. Markers of organ dysfunction (75%, 2 rounds), tissue perfusion (91.1%, 2 rounds) including lactate (94.6%, 2 rounds) and capillary refill time (76.8%, 2 rounds), assessment of fluid-responsiveness after initial resuscitation (92.9%, 5 rounds), and use of vasoactive drugs at norepinephrine equivalents greater than 0.5 µg/kg/min (75.0%, 3 rounds), were selected as clinical criteria of refractory septic shock. The use of critical care ultrasound (CCUS) (92.9%, 3 rounds) was the single diagnostic modality that reached a consensus-based agreement. CONCLUSIONS: A consensus for 13 criteria to frame the definition of refractory septic shock was reached. Refractory septic shock is characterised by persistently elevated lactate concentrations and or prolonged capillary refill time in patients with septic shock who are fluid unresponsive, require a norepinephrine base equivalent dose greater than 0.5 micrograms per kilogram per minute, and undergo CCUS assessment when mixed shock is suspected.

Abstract Myocardial bridging is the most common congenital coronary anomaly, characterized by an intramyocardial course of a segment of an epicardial coronary artery, with considerable variability in its depth and length. In most cases, MB is a benign anatomical variant without clinical significance, often asymptomatic and not requiring treatment. However, with the increasing use of coronary computed tomography angiography for coronary assessment, myocardial bridging is now more frequently identified during non-invasive imaging. It can also be diagnosed via invasive coronary angiography, where it appears as a dynamic systolic compression of the tunnelled artery segment, and further anatomical characterization can be enhanced by intravascular ultrasound or optical coherence tomography. Growing recognition of myocardial bridging’s role in ischaemia with non-obstructive coronary arteries has heightened clinical interest in its prevalence, diagnostic strategies, and management approaches. As such, this narrative review provides clinicians with an updated, evidence-based guide to the diagnosis and therapeutic management of myocardial bridging, while also addressing ongoing controversies and areas of uncertainty.