Prognostic role of lymphocyte to monocyte ratio in patients treated with CAR-T for aggressive lymphoma

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Background: A low absolute lymphocyte to monocyte ratio (ALC/AMC) has been found to predict decreased survival in lymphoma patients receiving chemotherapy and stem cell transplant. We report its clinical significance and additional cellular phenotype changes in patients receiving chimeric antigen receptor T-cell (CART) therapy. Methods: Records were reviewed for patients (pts) who received axicabtagene ciloleucel between 6/2016 and 12/2020. Receiver operator curve was generated using nominal logistic regression to predict CR as best response. Survivals were calculated using Kaplan- Meier method. Blood immune phenotype were assayed by multiparametric flow. Principle component analysis (PCA) was performed using ClusterVis. Results: Low ALC/AMC (≤0.8) prior to lymphodepletion (LD) chemotherapy on day -5 was associated with lower CR rate (AUC=0.68, Table). Our cohort of 81 pts had similar baseline characteristics except that noted in Table. Low ALC/AMC ratio is associated with shorter EFS and OS (EFS: 2.6 vs. 6.4 months, P<0.0001; OS: 5.3 months vs. not reached, P=0.0006), respectively. Prognostic association remained significant in multivariate analysis including ASCT, bridging therapy and CRP. Interestingly, compared to the high ALC/AMC group, the low ALC/AMC group had decreased CD8 Tem, increased CD16+CCR2+ monocytes and increased monocytes’ producing IL12, IL-10, and IL-1β (n=26). Unsupervised PCA identified 3 clusters: 1. Low ALC/AMC, all non-CR; 2. High ALC/AMC, some non-CR; 3. High ALC/AMC, all CR. Compared to cluster 1 and 2, cluster 3 had increased CD4 Tnaive, CD8 Tcm and IL-17 producing CD4 T and NK cells. Conclusions: ALC/AMC is a clinically accessible test that is strongly associated with CAR-T response and survival. Immune characterization revealed that the biologic effect is not just associated with cell ratio. Increased inflammation has been found to negatively impact CAR-T response, with some cytokines known to be from the myeloid lineage. We show that CRP is elevated in the low ALC/AMC group with increased cytokine production by monocytes. In addition, presence of T cell subset and IL-17 producing cells, before LD, are associated with clinical response. Further investigation on optimizing host immunity may help improve clinical outcome with CAR-T.[Table: see text]

Sciatic nerve palsy secondary to postoperative haematoma in primary total hip replacement

Sciatic nerve palsy is a recognised complication of primary total hip replacement. In our unit this complication was rare with an incidence of < 0.2% in the past ten years. We describe six cases of sciatic nerve palsy occurring in 355 consecutive primary total hip replacements (incidence 1.69%). Each of these palsies was caused by post-operative haematoma in the region of the sciatic nerve.

Cases, which were recognised early and surgically-evacuated promptly, showed earlier and more complete recovery. Those patients for whom the diagnosis was delayed, and who were therefore managed expectantly, showed little or no recovery. Unexpected pain and significant swelling in the buttock, as well as signs of sciatic nerve irritation, suggest the presence of haematoma in the region of the sciatic nerve.

It is, therefore, of prime importance to be vigilant for the features of a sciatic nerve palsy in the early post-operative period as, when recognised and treated early, the injury to the sciatic nerve may be reversed.

The 2-0 Ethilon test

Tight closure, which is a sign of ischemia secondary to tension, can lead to tissue necrosis. This article describes a simple and reliable test to help avoid excessive tension during skin closure.

The emotional impact of injury following an international terrorist incident

BACKGROUND

Terrorism represents a major public health threat throughout the world. Bombings of the United States Embassies in East Africa in 1998 resulted in extensive physical and emotional casualties.

METHODS

This study examined posttraumatic stress reactions, worry, and feelings of safety in the workplace in the context of injury in a convenience sample of 21 individuals directly exposed to the bombing in Dar es Salaam, Tanzania. Eight months postbombing, participants completed a self-report instrument examining demographics, exposure, injury, initial reaction, posttraumatic stress, worry, and feelings of safety in the workplace. Descriptive statistics and multiple regression were used to analyze the data. The "Impact of Event Scale-Revised" measured current posttraumatic stress.

RESULTS

Report of injury predicted posttraumatic stress, intrusion, and arousal but not avoidance/numbing. Injury and intrusion were significant predictors of ongoing worry.

CONCLUSIONS

Even relatively minor injury may be associated with ongoing posttraumatic stress and worry. The participants in the sample were all highly exposed which, along with the small sample size, may have limited the ability to establish other expected relationships.

Diverticulitis and polycystic kidney disease

Patients with adult polycystic kidney disease (PKD) have previously been shown to have an increased incidence of complicated diverticulitis after renal transplantation. The purpose of this study was to assess the risk of diverticulitis in the PKD population. We retrospectively reviewed patients with advanced PKD, defined as end-stage renal failure requiring dialysis. Patients were obtained from a single nephrology group practice between January 1985 and January 1997, or from all patients being evaluated or actively considered for renal transplantation at our institution as of May 1997. The incidence and severity of diverticulitis in these patients was compared with that observed in a similar cohort of patients with end-stage renal disease due to other etiologies. The study population consisted of 184 renal failure patients, 59 with PKD and 125 with other causes of end-stage renal disease. Twelve (20%) patients with PKD had a history of active diverticulitis, whereas only 4 (3%) of the non-PKD controls had diverticulitis (P = 0.0003, Fisher's exact test). Six of the 12 PKD patients required surgical intervention. Patients with renal failure due to PKD experience a significantly higher rate of diverticulitis than do other patients with end-stage renal disease. Furthermore, diverticulitis is frequently severe in PKD patients, with 50 per cent requiring surgical intervention. These data suggest that diverticular disease may be an extrarenal manifestation of polycystic kidney disease.

Loss of flexor pollicis longus function after plating of the radius. Report of six cases

Six cases of loss of flexor pollicis longus function after plating of a radius fracture are presented. The exact aetiology of the postoperative deficit is uncertain, but is probably a traction neuropraxia of the anterior interosseous nerve branches to the flexor pollicis longus. All six patients had full recovery within 5 months. An initial conservative approach is recommended if this complication is encountered.

CQI by committee: a multidisciplinary approach

Developing a continuous quality improvement program in preparation for a JCAHO survey can be a perplexing and sometimes redundant talk, especially if you're trying to define and remedy a new problem with old tools. Here's how one laboratory found a fresh approach to CQI by finding out what other hospital departments thought of the laboratory's service.

Taking responsibility for occlusion: the perfect occlusion

Patients free from occlusal dysfunction rarely have their teeth together. But, when occlusion does occur (i.e., swallowing), the contacts should be simultaneous and in such a manner as to direct the vector of force down the long axis of the tooth or implant. The incline planes should not touch.

The changing pattern of paramilitary punishments in Northern Ireland

Paramilitary punishments in Northern Ireland traditionally involved shooting in the limbs with low-velocity handguns. During the recent IRA ceasefire they were replaced with beatings by clubs and similar objects. We carried out a retrospective review of patients who had suffered punishment beatings who presented to the Royal Victoria Hospital, Belfast. Patients were more likely to have fractures and more severe soft-tissue injuries. The time spent in hospital was often longer, and there was a greater chance of requiring operations (often multiple).

Haemoprotein-mediated metabolism of enamines and the possible involvement of one-electron oxidations

1. Microsomal metabolism of 1-benzylpiperidine (1-BP), its cis-2,6-dimethyl (cis-2,6-DMBP), 4,4-dimethyl (4,4-DMBP), and alpha, alpha-dimethyl (alpha, alpha-DMBP) analogues, and phencyclidine (PCP) has been studied to assess the involvement of P450 oxidation of the enamine tautomers of the initial endocyclic iminium metabolites. 2. The selective prevention by cyanide of the metabolite production of 1-benzyl-3-piperidone but not 1-benzyl-3-piperidinol from 1-BP is consistent with the enamine as the source of the 3-one metabolite. 3. The parent amines and particularly the independently prepared iminium species induced a pattern of metabolism-dependent irreversible inactivation of P450 benz-phetamine demethylase activity, consistent with involvement of enamine C-3 oxidation in the inactivation process. 4. Substrate activity of the endocyclic enamines and alpha-aminoketones (presumably the enol-enamine tautomers) for horseradish peroxidase under conditions where simple aliphatic amines display no activity is consistent with metabolic one-electron oxidations of the enamines.

Chronic polychlorinated biphenyls exposure on three generations of oldfield mice (Peromyscus polionotus): effects on reproduction, growth, and body residues

Effects of chronic dietary exposure to low levels of PCBs (polychlorinated biphenyls) on reproduction, growth and whole body burdens were investigated in three generations of Peromyscus polionotus. Mated pairs were maintained on a diet containing 5 mg/kg PCBs (Aroclor 1254) for 12 months, beginning exposure as young adults; matched controls received a similar diet without PCBs. Offspring were maintained on the parental regime and paired at maturity with non-siblings in the same group. In first and second generation offspring, birth and weaning weights were significantly lower in PCB-exposed animals; in the second generation, there were also significantly fewer mice born/month, longer intervals prior to birth of the first litter, and decreased survival to weaning (25 days) among exposed mice. Whole body residue of PCBs increased significantly with each generation of exposure. This study clearly shows that chronic exposure to PCBs at a dosage of 5 mg/kg depressed fertility, growth and survival in Peromyscus, and that these effects were amplified through multigenerational exposure.

Discern--an integrated prospective decision support system

We present a new integrated decision support tool, called Discern, for prospective case management within a comprehensive Healthcare Network Architecture (HNA). Discern is an event-driven, expert system tightly integrated into this architecture. It can perform a variety of actions including generating alerts, ordering tests, and entering results. Over 100 institutions use Discern to automate care processes. Discern was designed to meet the demanding requirements for effective decision support.

Limited surgical intervention in the prune belly syndrome

Experience with 16 males with prune belly syndrome reveals that half have done well without any surgical treatment. The authors felt that two patients had unnecessary loop cutaneous ureterostomies--and inappropriate operation for these children. Urethral obstruction was found in two boys. Four neonates died of severe renal dysplasia. Although the distal ureters are dilated, they adequately conduct urine and seldom need shortening, tailoring, and reimplantation.

Influence of chronic ethanol consumption on the metabolism and carcinogenicity of tobacco-related nitrosamines

The effect of chronic ethanol consumption by Syrian golden hamsters (SGH) on the carcinogenicity and target tissue metabolism of N-nitroso-pyrrolidine (NPYR) and N'-nitrosonornicotine (NNN) has been examined. Ethanol-consuming hamsters treated with NPYR developed more nasal cavity and tracheal tumours than controls. Ethanol consumption did not affect the carcino-genicity of NNN. When the metabolism of NPYR and NNN by isolated tracheal rings was examined, it was observed that tracheal rings isolated from ethanol-consuming SGH metabolized NPYR at a higher rate than similar preparations from control animals. In contrast, no differences in the rates of metabolism of NNN were observed.