CD22 CAR T-cell associated hematologic toxicities, endothelial activation and relationship to neurotoxicity

BACKGROUND

Hematologic toxicities, including coagulopathy, endothelial activation, and cytopenias, with CD19-targeted chimeric antigen receptor (CAR) T-cell therapies correlate with cytokine release syndrome (CRS) and neurotoxicity severity, but little is known about the extended toxicity profiles of CAR T-cells targeting alternative antigens. This report characterizes hematologic toxicities seen following CD22 CAR T-cells and their relationship to CRS and neurotoxicity.

METHODS

We retrospectively characterized hematologic toxicities associated with CRS seen on a phase 1 study of anti-CD22 CAR T-cells for children and young adults with relapsed/refractory CD22+ hematologic malignancies. Additional analyses included correlation of hematologic toxicities with neurotoxicity and exploring effects of hemophagocytic lymphohistiocytosis-like toxicities (HLH) on bone marrow recovery and cytopenias. Coagulopathy was defined as evidence of bleeding or abnormal coagulation parameters. Hematologic toxicities were graded by Common Terminology Criteria for Adverse Events V.4.0.

RESULTS

Across 53 patients receiving CD22 CAR T-cells who experienced CRS, 43 (81.1%) patients achieved complete remission. Eighteen (34.0%) patients experienced coagulopathy, of whom 16 had clinical manifestations of mild bleeding (typically mucosal bleeding) which generally subsided following CRS resolution. Three had manifestations of thrombotic microangiopathy. Patients with coagulopathy had higher peak ferritin, D-dimer, prothrombin time, international normalized ratio (INR), lactate dehydrogenase (LDH), tissue factor, prothrombin fragment F1+2 and soluble vascular cell adhesion molecule-1 (s-VCAM-1). Despite a relatively higher incidence of HLH-like toxicities and endothelial activation, overall neurotoxicity was generally less severe than reported with CD19 CAR T-cells, prompting additional analysis to explore CD22 expression in the central nervous system (CNS). Single-cell analysis revealed that in contrast to CD19 expression, CD22 is not on oligodendrocyte precursor cells or on neurovascular cells but is seen on mature oligodendrocytes. Lastly, among those attaining CR, grade 3-4 neutropenia and thrombocytopenia were seen in 65% of patients at D28.

CONCLUSION

With rising incidence of CD19 negative relapse, CD22 CAR T-cells are increasingly important for the treatment of B-cell malignancies. In characterizing hematologic toxicities on CD22 CAR T-cells, we demonstrate that despite endothelial activation, coagulopathy, and cytopenias, neurotoxicity was relatively mild and that CD22 and CD19 expression in the CNS differed, providing one potential hypothesis for divergent neurotoxicity profiles. Systematic characterization of on-target off-tumor toxicities of novel CAR T-cell constructs will be vital as new antigens are targeted.

TRIAL REGISTRATION NUMBER

NCT02315612.

The role of women's leadership and gender equity in leadership and health system strengthening

Gender equity is imperative to the attainment of healthy lives and wellbeing of all, and promoting gender equity in leadership in the health sector is an important part of this endeavour. This empirical research examines gender and leadership in the health sector, pooling learning from three complementary data sources: literature review, quantitative analysis of gender and leadership positions in global health organisations and qualitative life histories with health workers in Cambodia, Kenya and Zimbabwe. The findings highlight gender biases in leadership in global health, with women underrepresented. Gender roles, relations, norms and expectations shape progression and leadership at multiple levels. Increasing women's leadership within global health is an opportunity to further health system resilience and system responsiveness. We conclude with an agenda and tangible next steps of action for promoting women's leadership in health as a means to promote the global goals of achieving gender equity.

FALLS-protocol: lung ultrasound in hemodynamic assessment of shock

The assessment of acute circulatory failure is a challenge in absence of solid gold standard. It is suggested that artifacts generated by lung ultrasound can be of help. The FALLS-protocol (Fluid Administration Limited by Lung Sonography) follows Weil's classification of shocks. Firstly, it searches for pericardial fluid, then right heart enlargment, lastly abolished lung sliding. In this setting, the diagnoses of pericardial tamponade, pulmonary embolism and tension pneumothorax, i.e. obstructive shock, can be schematically ruled out. Moreover, the search of diffuse lung rockets (i.e. multiple B-lines, a comet-tail artifact) is performed. Its absence excludes pulmonary edema, that in clinical practice is left cardiogenic shock (most cases). At this step, the patient (defined FALLS-responder) receives fluid therapy. He/she has usually a normal sonographic lung surface, an A-profile. Any clinical improvement suggests hypovolemic shock. The absence of improvement generates continuation of fluid therapy, eventually yielding fluid overload. This condition results in the change from A-profile to B-profile. Lung ultrasound has the advantage to demonstrate this interstitial syndrome at an early and infraclinical stage (FALLS-endpoint). The change from horizontal A-lines to vertical B-lines can be considered as a direct marker of volemia in this use. By elimination, this change indicates schematically distributive shock, while in current practice septic shock. The major limitation is the B-profile on admission generated by an initial lung disorder. FALLS-protocol, which can be associated with no drawback with traditional hemodynamic tools, uses a simple machine (without Doppler) and a suitable microconvex probe allowing for heart, lung and vein assessment.

Lung ultrasound in acute respiratory failure an introduction to the BLUE-protocol

Critical ultrasound, apparently a recent field, is in fact the outcome of a slow process, initiated since 1946. The lung was traditionally not considered as part of ultrasound, yet we considered its inclusion as a priority in our definition of critical ultrasound. Acute respiratory failure is one of the most distressing situations for the patient. An ultrasound approach of this disorder - the BLUE-protocol allows rapid diagnosis. Its main features will be described. Each kind of respiratory failure provides a particular ultrasound profile. In this difficult setting, initial mistakes are frequent. The BLUE-protocol proposes a step-by-step approach for making accurate diagnosis. By combining three signs with binary answer (anterior lung sliding, anterior lung-rockets), with venous analysis when required, seven profiles are generated, yielding a 90.5% accuracy. This rate is highly enhanced when simple clinical and laboratory data are considered. The BLUE-protocol can be achieved in three minutes, because the use of an intelligent machine, a universal probe, and standardized points allow major time-saving. Lung ultrasound in the critically ill was long available. In a domain where everything must be fast and accurate, the BLUE-protocol can play a major role in the diagnosis of an acute respiratory failure, usually answering immediately to questions where only sophisticated techniques were hitherto used.

The Internal jugular veins are asymmetric. Usefulness of ultrasound before catheterization

OBJECTIVE

To demonstrate an asymmetry of the internal jugular veins, a finding which will have consequences for catheterization.

DESIGN

Prospective study.

SETTING

The medical ICU of a university-affiliated teaching hospital.

PATIENTS

Eighty critically ill consecutive patients.

INTERVENTION

Measurement of the cross-sectional area of the internal jugular veins. Search for an asymmetry, defined as an area at least twice that of the contralateral vein.

RESULTS

An asymmetry was noted in 62.5% of the patients. The dominant vein was the right in only 68 % of these cases. In addition, 23% of the 160 jugular internal veins had an area of 0.4 cm2 or less.

CONCLUSIONS

Using a simple technique, ultrasound identifies the dominant internal jugular vein, thus indicating the safer side before blind catheterization.

The "lung point": an ultrasound sign specific to pneumothorax

OBJECTIVE

We studied an ultrasound sign, the fleeting appearance of a lung pattern (lung sliding or pathologic comet-tail artifacts) replacing a pneumothorax pattern (absent lung sliding plus exclusive horizontal lines) in a particular location of the chest wall. This sign was called the "lung point".

DESIGN

Prospective study.

SETTING

The medical ICU of a university-affiliated teaching hospital.

PATIENTS

The "lung point" was sought in 66 consecutive cases of proven pneumothorax analyzable using ultrasound--including 8 radio-occult cases diagnosed by means of CT and in 233 consecutive hemithoraces studied by CT and free of pneumothorax-- including 17 cases where pneumothorax was suspected.

RESULTS

The "lung point" was observed in 44 of 66 cases of pneumothorax (including 6 of 8 radio-occult cases) and in no case in the control group. The location of this sign roughly correlated with the radiological size of the pneumothorax. The "lung point" therefore had an overall sensitivity of 66 % (75 % in the case of radio-occult pneumothorax alone) and a specificity of 100%.

CONCLUSION

The presence of a "lung point" allows positive diagnosis of pneumothorax at the bedside using ultrasound.

Feasibility and safety of ultrasound-aided thoracentesis in mechanically ventilated patients

OBJECTIVE

Thoracentesis in a ventilated patient is rarely performed because of the risk of pneumothorax. We have evaluated the safety of this procedure when aided by ultrasound.

DESIGN

Prospective study.

SETTING

Medical intensive care unit, university-affiliated hospital.

PATIENTS

45 procedures were performed in 40 consecutive patients with ultrasound signs of pleural effusion, all mechanically ventilated.

INTERVENTIONS

Pleural effusion was defined on ultrasound as a collection of fluid between parietal and visceral pleura leading to variations in interpleural distance during breathing. When the interpleural distance was >/= 15 mm and visible over three intercostal spaces, a needle (16 or 21 G) was inserted after ultrasound localization in a patient in either dorsal or lateral decubitus.

RESULTS

No complication occurred in the 45 thoracenteses. Fluid was obtained in 44 of 45 procedures, thus confirming the diagnosis of pleural effusion. The procedure was immediate (less than 10 s) in 40 of 45 cases. It was easy (i. e., keeping the patient supine) in 22 of 45 procedures. In 44 cases where fluid was obtained, only 27 bedside radiographs revealed signs of effusion, whereas 17 showed absence of a visible effusion. Ultrasound thus appeared more efficient than bedside X-ray in detecting pleural effusion.

CONCLUSIONS

If basic rules are followed, ultrasound localization makes thoracentesis a safe, easy and simple procedure in patients on mechanical ventilation.

The comet-tail artifact: an ultrasound sign ruling out pneumothorax

OBJECTIVE

Ultrasound artifacts arising from the lung-wall interface are either vertical (comet-tail artifacts) or horizontal. The significance of these artifacts for the diagnosis of pneumothorax was assessed.

DESIGN

Prospective clinical study.

SETTING

The medical ICU of a university-affiliated teaching hospital.

PATIENTS

We compared 41 complete pneumothoraces with 146 hemithoraces in 73 critically ill patients in which computed tomography showed absence of pneumothorax.

MEASUREMENTS

The anterior chest wall was investigated in supine patients using a portable device. The test was defined as positive for complete pneumothorax when only horizontal artifacts were visible, and negative when artifacts arising from the pleural line and spreading up to the edge of the screen (referred to as "comet-tail artifacts") were present.

RESULTS

The feasibility was 98%. Ultrasound showed exclusive horizontal artifacts in all 41 analyzable cases of complete pneumothorax. In the pneumothorax-free group, "comet-tail artifacts" were present in 87 cases and exclusive horizontal artifacts in 56. Ultrasound as well as computed tomography showed anterior consolidation or anterior pleural effusion in three cases. Horizontal artifacts had a sensitivity and a negative predictive value of 100% and a specificity of 60% for the diagnosis of pneumothorax. Horizontal artifacts and absent lung sliding, when combined, had a sensitivity and a negative predictive value of 100% and a specificity of 96.5%.

CONCLUSIONS

Ultrasound detection of the "comet-tail artifact" at the anterior chest wall allows complete pneumothorax to be discounted.

A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact

OBJECTIVE

Acute cardiogenic pulmonary edema and exacerbation of chronic obstructive pulmonary disease (COPD) can have a similar clinical presentation, and X-ray examination does not always solve the problem of differential diagnosis. The potential of lung ultrasound to distinguish these two disorders was assessed.

DESIGN

Prospective clinical study.

SETTING

The medical ICU of a university-affiliated teaching hospital.

PATIENTS

We investigated 66 consecutive dyspneic patients: 40 with pulmonary edema and 26 with COPD. In addition, 80 patients without clinical and radiologic respiratory disorders were studied.

MEASUREMENTS

The sign studied was the comet-tail artifact arising from the lung wall interface, multiple and bilaterally disseminated to the anterolateral chest wall.

RESULTS

The feasibility was 100%. The length of the examination was always under 1 min. The described pattern was present in all 40 patients with pulmonary edema. It was absent in 24 of 26 cases of COPD as well as in 79 of 80 patients without respiratory disorders. The sign studied had a sensitivity of 100% and a specificity of 92% in the diagnosis of pulmonary edema when compared with COPD.

CONCLUSIONS

With a described pattern present in 100% of the cases of pulmonary edema and absent in 92% of the cases of COPD and in 98.75% of the normal lungs, ultrasound detection of the comet-tail artifact arising from the lung-wall interface may help distinguish pulmonary edema from COPD.

The "sinusogram", a real-time ultrasound sign of maxillary sinusitis

OBJECTIVE

To describe a real-time ultrasound sign, the visualization of the cavity and the walls of the maxillary sinus ("sinusogram"), and to assess its correlation with total opacity of the sinus.

DESIGN

Prospective clinical study.

SETTING

The medical ICU of a university-affiliated hospital.

PATIENTS

The significance of this sign was assessed in 50 critically ill supine patients (100 maxillary sinuses) who underwent paranasal CT.

MEASUREMENTS AND RESULTS

The "sinusogram" was defined as complete when the internal, external and posterior walls were frankly visible, and incomplete in the case of partial visualization of the walls. The "sinusogram" was present in all 21 cases of total opacity, in 2 of 12 cases of air-fluid level, in 8 of 14 cases of mucosal thickening, in one giant polyp, and in none of 52 normal sinuses. The "sinusogram" was complete in 10 of 21 cases of total opacity. It was incomplete in 11 of 21 cases of total opacity and in all 8 cases of mucosal thickening with positive ultrasound. For the diagnosis of radiologic maxillary sinusitis (total opacity or air-fluid level within the maxillary cavity), the sensitivity was 67 % and the specificity 87 %. For the diagnosis of total opacity (versus absence of total opacity, which includes fluid level), the sensitivity was 100% and the specificity 86%. When the "sinusogram" was complete, the specificity was 100% for the diagnosis of total opacity.

CONCLUSIONS

Ultrasound may be proposed in first-line diagnosis of radiologic maxillary sinusitis.

The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome

Can ultrasound be of any help in the diagnosis of alveolar-interstitial syndrome? In a prospective study, we examined 250 consecutive patients in a medical intensive care unit: 121 patients with radiologic alveolar-interstitial syndrome (disseminated to the whole lung, n = 92; localized, n = 29) and 129 patients without radiologic evidence of alveolar-interstitial syndrome. The antero-lateral chest wall was examined using ultrasound. The ultrasonic feature of multiple comet-tail artifacts fanning out from the lung surface was investigated. This pattern was present all over the lung surface in 86 of 92 patients with diffuse alveolar-interstitial syndrome (sensitivity of 93.4%). It was absent or confined to the last lateral intercostal space in 120 of 129 patients with normal chest X-ray (specificity of 93.0%). Tomodensitometric correlations showed that the thickened sub-pleural interlobular septa, as well as ground-glass areas, two lesions present in acute pulmonary edema, were associated with the presence of the comet-tail artifact. In conclusion, presence of the comet-tail artifact allowed diagnosis of alveolar-interstitial syndrome.

Von Hippel-Lindau disease complicated by acute pancreatitis and Evan's syndrome

Von Hippel-Lindau syndrome (VHL) is an autosomal dominant disorder characterized by renal cysts, retinal angiomas, central nervous system hemangioblastomas, and pancreatic cysts. Evan's syndrome is a hematologic disorder characterized by autoimmune thrombocytopenia and autoimmune hemolytic anemia. We present the first case of acute pancreatitis and Evan's syndrome that developed in a patient with von Hippel-Lindau syndrome.

The membrane-associated and secreted forms of the respiratory syncytial virus attachment glycoprotein G are synthesized from alternative initiation codons

Respiratory syncytial (RS) virus synthesizes two mature forms of its attachment glycoprotein G: an anchored type II integral membrane form and a smaller form that is secreted into the medium. Here we demonstrate that these two forms are synthesized as distinct primary translation products of a single species of G protein mRNA by initiation at either of two different AUGs. Mutant cDNAs which eliminated one of the other of the two AUG codons near the 5' end of the G gene open reading frame were constructed. Analysis of the proteins synthesized from these cDNAs, either by translation of transcripts in a cell-free system or in cells infected with recombinant vaccinia viruses containing either one of the mutant cDNAs, showed that elimination of either the first or the second of these AUG codons abrogated the synthesis of the membrane-anchored or the secreted form of the protein, respectively. Additionally, two unglycosylated forms of G protein which comigrated with the unglycosylated G proteins expressed by these recombinant viruses were detected in RS virus-infected cells. Since the second AUG encodes a methionine residue that lies near the middle of the signal/anchor domain, initiation at this codon resulted in a protein with a hydrophobic amino terminus. This form of the glycoprotein was efficiently secreted from cells infected with the vaccinia virus recombinant, and the amino-terminal sequence of this protein was identical to that of G protein secreted from RS virus-infected cells. Our results demonstrate that the secreted form of RS virus G protein is produced by initiation at the second AUG codon of the G open reading frame, followed by proteolytic removal of the signal/anchor domain.

Intensive use of general ultrasound in the intensive care unit. Prospective study of 150 consecutive patients

OBJECTIVE

To assess the impact of systematic ultrasound (US) examination in patients admitted to the ICU.

DESIGN

An observational study of 150 consecutive patients.

SETTING

A medical ICU of a University-affiliated hospital.

PATIENTS

All consecutively admitted patients were examined, but patients discharged within < 48 h were excluded from the analysis.

INTERVENTIONS

A systematic examination of the abdomen, pleural space, cervical and femoral vein, was performed at the bedside by the same investigator.

MEASUREMENTS

Results of US examinations were compared to findings from CT-scan, surgery, endoscopic procedures, autopsy, or other diagnostic tests. The impact of U.S. findings on immediate patients management was evaluated.

RESULTS

In 33 of 150 patients (22%), U.S. findings influenced the diagnosis, work up of the patients, and had a direct impact on the therapeutic plan. In 30/33 cases, confirmation of diagnosis was obtained by another diagnostic and/or therapeutic procedure.

CONCLUSIONS

Routine US examination may alter therapeutic plans in up to 1/4 of critically ill patients admitted to the ICU. US examination should be liberally performed on such patients.

Skin petechiae and ecchymoses (vasculitis) due to anticoagulant therapy

The appearance of petechiae and ecchymoses following anticoagulant and fibrinolytic therapy is an unusual and rare complication. The mechanism of the vasculitis is obscure but may be related to a chemical vasotoxic reaction. During anticoagulant and fibrinolytic therapy, 6 patients developed petechiae and ecchymoses which was accompanied by pain and fever. There were no disturbances of blood clotting factors. In spite of the varied action of the different anticoagulants and fibrinolytic drugs, the clinical course and the histological examination demonstrated a similar identical vasculitis.

Fournier's gangrene complicating perinal abscess: report of two cases

Two cases of Fournier's gangrene in which toxemia and gangrene of the scrotum developed due to perianal abscesses are described. Cultures of anaerobic gram-negative Bacteroides with a mixed flora of Pseudomonas, E. coli and Proteus were obtained. Early diagnosis, wide and deep incisions, debridement of the necrotic tissue, and adequate antibiotic therapy can prevent a fatal outcome of this disease. A high mortality rate is still prevalent.

Acute myocardial infarction and arterial embolectomy

Emboli of a main artery cause serious complications in patients suffering from acute myocardial infarction, in whom the surgical risk is high. In order to save the limb, embolectomy is indicated and should be considered. Early diagnosis and prompt surgical intervention with the use of the Fogarty catheter simplify the embolectomy procedure and enable restoration of circulation to the ischaemic limb. Thirty-two embolectomies were performed in twenty-eight patients suffering from acute myocardial infarction. Patients with cardiac compensation survived the surgery and recovered. However 50% of the patients in whom acute myocardial infarction was accompanied with congestive heart failure and arrhythmias died. The cause of death was the underlying disease. Considering the severity of the acute myocardial infarction this group of patients represents the expected mortality.