Thrombopoietin receptor agonist for treating bone marrow aplasia following anti-CD19 CAR-T cells-single-center experience

Anti CD-19 chimeric antigen receptor T (CAR-T) cells demonstrate effective early anti-tumor response; however, impaired hematopoietic recovery is observed in about 30% of patients with prolonged cytopenia appearing as an unmet need for optimal treatment. All adult patients given commercially available anti CD-19 CAR-T for diffuse large B cell lymphoma (DLBCL) were screened at 21-28 days after CAR-T infusion for cytopenia. In case of severe persistent cytopenia, patients were given TPO receptor agonists. Initial dose of eltrombopag was 50 mg/day and gradually increased to a maximal dose of 150 mg/day. Romiplostim was given as subcutaneous injection once a week for 2 doses (125 mcg). Response was defined as transfusion independency along with resolution of severe neutropenia (ANC > 500 /microL) and/or platelets > 20,000/microL for three consecutive values on different days. TPO receptor agonists were tapered down when response was met. From May 2019 to December 2021, 93 patients were eligible (74%, tisagenlecleucel and 26%, axicabtagene ciloleucel). The median age was 69 (range, 19-85) years. Six patients (6.5%) (tisagenlecleucel, n = 4 or axicabtagene ciloleucel, n = 2) demonstrated prolonged severe cytopenia and were treated with TPO receptor agonists (eltrombopag, n = 4; romiplastim, n = 1, both drugs, n = 1). Median time from CAR-T infusion to initiation of TPO receptor agonist was 43 (range, 21-55) days. All patients were transfusion-dependent and were given daily GCSF prior to TPO receptor agonist administration. Response to TPO receptor agonists was seen in all 6 patients. Median time from TPO receptor agonist initiation to resolution of cytopenia was 22 (range, 8-124) days for Hb, 27 (range, 6-38) days for platelets, and 29 (range, 7-61) days for neutrophils. A complete resolution of all blood counts (ANC > 500 /microL and platelets > 20,000/microL and hemoglobin > 8 gr/dL) was seen in 5/6 patients. No toxicity was observed during the therapy course. This paper supports further investigation of TPO receptor agonists in the treatment of persistent cytopenia following CAR-T cell therapy.

Assessment of a semiautomated pelvic floor measurement model for evaluating pelvic organ prolapse on MRI

INTRODUCTION AND HYPOTHESIS

The objective of this study was to assess the performance of a semiautomated pelvic floor measurement algorithmic model on dynamic magnetic resonance imaging (MRI) images compared with manual pelvic floor measurements for pelvic organ prolapse (POP) evaluation.

METHODS

We examined 15 MRIs along the midsagittal view. Five reference points used for pelvic floor measurements were identified both manually and using our semiautomated measurement model. The two processes were compared in terms of accuracy and precision.

RESULTS

The semiautomated pelvic floor measurement model provided highly consistent and accurate locations for all reference points on MRI. Results also showed that the model can identify the reference points faster than the manual-point identification process.

CONCLUSION

The semiautomated pelvic floor measurement model can be used to facilitate and improve the process of pelvic floor measurements on MRI. This will enable high throughput analysis of MRI data to improve the correlation analysis with clinical outcomes and potentially improve POP assessment.

Vaginal evisceration long after vaginal hysterectomy

BACKGROUND

Vaginal evisceration can take place many years after vaginal surgery.

CASE

An 87-year-old woman presented with evisceration of small bowel through the vagina, 15 years after she underwent a vaginal hysterectomy. On physical examination, her vital signs were normal. Forty centimeters of small bowel was visible emerging from the vagina, appearing viable and nonedematous. Because of the high surgical risk, the bowel was replaced and the defect in the vaginal wall was repaired transvaginally.

CONCLUSION

Vaginal evisceration can be treated by a transvaginal surgical approach. Factors such as the medical condition of the patient and the viability of the herniated viscus should dictate the optimal approach in each case.

Mechanism of action of interleukin-2 (IL-2)-Bax, an apoptosis-inducing chimaeric protein targeted against cells expressing the IL-2 receptor

The chimaeric protein interleukin-2 (IL-2)-Bax was designed to target and kill specific cell populations expressing the IL-2 receptor. However, it is not well understood how IL-2-Bax causes target cells to die. In the present study, we investigated the pathway of apoptosis evoked by IL-2-Bax and the possible involvement of endogenous Bax in this process. We report here that, upon internalization of IL-2-Bax into target cells, it is localized first mainly in the nucleus, and only later is it translocated to the mitochondria. Similarly, endogenous Bax is also partially localized in the nucleus, and accumulates mainly in this compartment soon after physiological triggering of apoptosis. Despite the fact that Bax has no nuclear localization sequence, our data suggest that Bax has one or more physiological roles and/or substrates within the nucleus. Indeed, a dramatic repression of nuclear Tax protein expression was induced following treatment of HUT-102 cells with IL-2-Bax, similar to what occurs following serum deprivation of these cells. Unexpectedly, induction of apoptosis using IL-2-Bax was preceded by enhanced expression of newly synthesized Bax protein and suppression of Bcl-2. This imbalance between the pro- and anti-apoptotic genes was associated with p53 induction, although IL-2-Bax activity was also evident in cells lacking p53 expression. By studying the mechanism of action of IL-2-Bax, we were able to follow the intrinsic events and their cascade that culminates in cell death. We have shown that the ability of IL-2-Bax to affect the intracellular apoptotic machinery within the target cells, and to cause the cells to die, uses a mechanism similar to that induced following a normal apoptotic signal.

Periodic, profound peripheral vasoconstriction--a new marker of obstructive sleep apnea

We report a novel approach to the determination of sleep apnea based on measuring the peripheral circulatory responses in a primary condition of disordered breathing. The apparatus is a finger plethysmograph coupled to a constant volume, variable pressure, pneumatic system. The plethysmograph's tip (measurement site) is composed of two parallel opposing longitudinal half thimbles, which is attached to a contiguous annular cuff. Each compartment consists of an internal membrane surrounded by an outer rigid wall. These provide a uniform pressure field and impart a two-point locking action preventing axial and longitudinal motion of the finger. Subdiastolic pressure is applied to prevent venous pooling, engorgement, and stasis, to inhibit retrograde venous shock wave propagation and partially unload arterial wall tension. The annular cuff extends the effective boundary of the pressure field beyond the measuring site. In 42 patients with Obstructive Sleep Apnea Syndrome (OSAS) profound, transient vasoconstriction and tachycardia usually of a periodic nature, were clearly seen with each apneic event, possibly related to transient arousal. Good agreement was found between standard total apnea-hypopnea scoring, 129.5+/-22.4 (Mean +/- SEM), and transient vasoconstriction and tachycardia events, 121.2+/-19.4 (R = .92, p<.0001). We conclude that the finger tip exemplifies the scope of peripheral vascular responsiveness due to its high density of alpha sympathetic innervation, and its high degree of blood flow rate lability. Given that elevated peripheral resistance and tightly linked transient heart rate elevation is a consistent part of the hemodynamic response to arousal and OSAS, we believe that pulsatile finger blood flow patterns can be clearly diagnostic of OSAS and other sleep-disordered breathing conditions.

[Color coded Doppler ultrasound in diagnosis of gastroesophageal reflux]

We report the possibility to detect small gastro-oesophageal refluxes by means of colour coded Doppler(CD)ultrasonography. The choice of an adequate pulse repetition frequency, which coded velocities up to 30 cm/s into colour without aliasing phenomenon, is an important premise for a colour coded proof of reflux. The sensitivity has been increased from 87% to 94% in sonographically detection of reflux, if the results are compared with the pH metry, measured about 24 hours. It is shown by comparison of the three methods (B-mode-, CD-ultrasonography and 24 hours pH-monitoring), that there are in each case equal false negative and false positive results. So the over all agreement was just 83% of all three methods. In our opinion it should be performed an additional ultrasonography in completion to the customary pH metry, which can detect even short term and pH neutral refluxes. If it is used supplementary, the colour coded Doppler ultrasonography improves the diagnostic sensitivity especially in trifle refluxes.

Color doppler in the diagnosis of the gastroesophageal reflux in children: comparison with pH measurements and B-mode ultrasound

Eighty-four high risk children were examined for suspected gastroesophageal reflux comparing 24-h esophageal pH measurements with ultrasound (US) scans with and without the use of color Doppler (CD). In 83.3 % of the patients there was unequivocal agreement (reflux or no reflux) among all three techniques; 60.7 % of the children showed reflux by pH-metry as compared to 51.2 % by B-mode US and 59.5 % by CD US. In 87 % of patients there was agreement between pH-metry and B-mode US as compared to 94 % between pH-metry and CD US. The sensitivity of reflux detection increased from 84.4 % to 98 % when CD was added to B-mode US. This improvement was thought to be due to the higher sensitivity of CD for rapid and small quantities of reflux. The small number of discrepancies between pH-metry and CD US is probably due to the inability of the former to detect neutral reflux of contents or short duration (< 30 s), while CD US may miss some cases of acid reflux due to the short time of the examination (10 min). The addition of CD increases the sensitivity of US for detecting reflux. This rapid, easy and reliable method can be used to screen high risk populations when reflux is thought to be the cause of respiratory symptoms.

Detection of increased blood flow to the affected arm in repetitive strain injury with radionuclide and Doppler ultrasound studies. A case report

A case of clinically diagnosed repetitive strain injury was referred for investigation to rule out the possibility of an occult bone disease. The patient was a female keyboard operator who had pain and tenderness over the flexor muscles of the right hand and arm. The pain was severe and almost constant. The authors observed an increase in Tc-99m MDP delivery to the affected forearm during the dynamic sequence of a three-phase bone scintigram, indicating increased blood flow compared to the contralateral side. The same result was achieved using quantitative blood flow measurements with the Doppler technique and Tc-99m HMPAO perfusion imaging. These findings agree with recent studies that suggest increased total arm blood flow in repetitive strain injury and may provide an easy screening method.

Adaptive speckle reduction for improving the differential diagnosis of breast lesions

Adaptive speckle reduction could mask diagnostic features and adversely affect diagnosis of focal breast lesions. Four radiologists assessed focal breast lesions (29 malignant and 31 benign) by blind review of representative static B-mode scans before and after adaptive speckle reduction processing, scoring 14 diagnostic features for breast cancer and recording their opinions on the diagnosis and on how adaptive speckle reduction affected interpretation of each feature. No adverse affect on diagnosis of malignant (P = 0.756) or benign (P = 1.000) breast lesions was found, despite some differences in scoring of the diagnostic features after adaptive speckle reduction. Observer recognition of most diagnostic features was easier after adaptive speckle reduction (e.g., edge definition [50% of cases], edge regularity [40%], lesion texture [44%], and lesion echogenicity [35%]).

Cellular versus vascular rejection in transplant kidneys. Correlation of radionuclide and Doppler studies with histology

The presence of two distinct subtypes of renal allograft rejection are well documented by histological studies. The differentiation between vascular rejection (VR) and cellular rejection (CR) is essential for proper management by avoiding the need for unnecessary and potentially harmful immunosuppressive treatment of VR. A histological pattern with features that are similar and confusable with some cases of rejection may be seen in cyclosporin A toxicity (CyT). To evaluate the efficiency of Guy's perfusion index (GPI) and the Doppler pulsatility index (DPI) in differentiating these two histological subtypes, a prospective study was designed in which a total of 140 radionuclide tests and 133 ultrasounds scans performed on the same day on 58 patients during the first 3 months post-transplant were analysed, and the results correlated with the histological findings of 84 renal biopsies. Results show that the GPI had a sensitivity of 86.5% and a specificity of 94% in differentiating VR and CyT from CR, while the DPI had values of 83% and 69%, respectively. Chi-squared analysis showed a higher significant association between the GPI and histology (P < 0.0001) compared to that of the DPI and histology (P < 0.005), while Youden's index (J) showed a significant difference (P < 0.05) between GPI and DPI. It is concluded that GPI is more sensitive and specific than DPI in differentiating transplants that are well perfused from those with poor perfusion (VR and CyT).