[Blood pressure variability : useful, trivial or potentially dangerous ?]

Usually, blood pressure variability is an adaptive physiological process allowing optimal perfusion of internal organs every time and in every clinical situation. This variability may nevertheless be excessive and then be associated with a poor cardiovascular and renal but also neurological prognosis. An excess in blood pressure variability may also be responsible for unpleasant symptoms in some patients. The different types of blood pressure variability, their causes and consequences as well as the mean to improve its control will be discussed in this article.

A Model to Estimate Cytokine Release Syndrome and Neurological Event Management Costs Associated With CAR T-Cell Therapy

Chimeric antigen receptor (CAR) T-cell therapies demonstrated efficacy in relapsed/refractory large B-cell lymphoma (LBCL) but are associated with cytokine release syndrome (CRS) and neurological events (NE). We wanted to estimate the total cost of CRS and NE management among patients with relapsed/refractory LBCL treated with lisocabtagene maraleucel (liso-cel), axicabtagene ciloleucel (axi-cel), or tisagenlecleucel (tisa-cel) in the third- or later-line setting. An economic decision tree model was developed using clinical and economic data to estimate a weighted average per-patient adverse event (AE) management cost from a United States health care system perspective in 2020 dollars. In 2 predefined analyses, mean expected cost and 95% confidence intervals of the average treated patient were estimated via Monte Carlo simulations, with per-patient costs for each CAR T-cell therapy further stratified by AE and grade. In the base case, the overall weighted average per-patient cost was $18,718, $47,665, and $42,538 for liso-cel, axi-cel, and tisa-cel, respectively. The weighted average per-patient cost per CRS event was $8213, $20,442, and $26,009 for liso-cel, axi-cel, and tisa-cel, respectively; the weighted average per-patient cost per NE was $10,505, $27,223, and $16,528, respectively. Differences in the base-case scenario estimated total mean costs for liso-cel were -$28,947 and -$23,819 compared with axi-cel and tisa-cel, respectively. In the scenario analysis (alternative cost input), differences in the estimated total mean costs were -$24,498 for liso-cel versus axi-cel, and -$19,326 for liso-cel versus tisa-cel. Across the base case and scenario analysis, liso-cel had the lowest weighted average CRS and NE costs per treated patient compared with axi-cel and tisa-cel owing to lower incidence rates and symptom severity. These findings highlight the economic implications of differences in safety among CAR T-cell therapies.

Clinical experience of CAR T cell therapy in lymphomas

Non-Hodgkin lymphoma in relapse portends a poor prognosis due to resistance to cytotoxic chemotherapy and monoclonal antibodies. Chimeric Antigen receptor (CAR) T cell therapy has been tested in many lymphomas in the relapse refractory setting and has resulted in durable responses despite some peculiar side effects including cytokine release syndrome (CRS), neurological events (NE), prolonged cytopenias and hypogammaglobulinemia. This review summarizes the registration trials conducted in lymphomas. All products showed response rates that were far better than obtainable by salvage chemotherapy and most patients recovered from side effects including CRS and NEs. The impact of CAR T in the real world setting was discussed as well as how to approach the use of CAR T in special circumstances such as CNS involvement, management of post CAR relapses and outpatient therapy.

Heart Failure Association of the European Society of Cardiology position paper on the management of left ventricular assist device-supported patients for the non-left ventricular assist device specialist healthcare provider: Part 2: at the emergency department

The improvement in left ventricular assist device (LVAD) technology and scarcity of donor hearts have increased dramatically the population of the LVAD‐supported patients and the probability of those patients to present to the emergency department with expected and non‐expected device‐related and patient–device interaction complications. The ageing of the LVAD‐supported patients, mainly those supported with the ‘destination therapy’ indication, increases the risk for those patients to suffer from other co‐morbidities common in the older population. In this second part of the trilogy on the management of LVAD‐supported patients for the non‐LVAD specialist healthcare provider, definitions and structured approach to the LVAD‐supported patient presenting to the emergency department with bleeding, neurological event, pump thrombosis, chest pain, syncope, and other events are presented. The very challenging issue of declaring death in an LVAD‐supported patient, as the circulation is artificially preserved by the device despite no other signs of life, is also discussed in detail.

Investigating the association of receipt of seasonal influenza vaccine with occurrence of anesthesia/paresthesia and severe headaches, Canada 2012/13-2016/17, the Canadian Vaccine Safety Network

BACKGROUND

Concern about adverse events following immunization is frequently cited by both those who receive or decline vaccines. Neurological adverse events are especially concerning.

OBJECTIVES

Our aim was to detect associations between seasonal influenza vaccination and the occurrence of severe anesthesia/paresthesia or severe headaches.

METHODS

Data were analyzed from the Canadian National Vaccine Safety network. Events occuring on days 0-7 were self-reported and prevented daily activity, led to school or work absenteeism, or required medical attention. Controls were the previous year's vaccinees; events in controls were collected prior to the start of the influenza vaccination program of each year (2012/13 through 2016/17). Multivariable logistic regression was used to determine the association between seasonal influenza vaccination and the occurrence of anesthesia/paresthesia or severe headaches.

RESULTS

The total sample was 107,565 for investigating anesthesia/paresthesia and 97,420 for investigating severe headaches. Anesthesia/paresthesia was reported by 104/107,565 (0.10%) participants; 63/69,129 (0.09%) vaccinees and 41/38,436 (0.11%) controls (adjusted odds ratio (aOR) = 0.89; 95% CI = 0.60, 1.32). Severe headaches were reported by 1361/97,420 (1.40%) participants; 907/61,463 (1.48%) vaccinees and 454/35,957 (1.26%) controls (aOR = 1.21; 95% CI = 1.08, 1.36). No specific vaccine product was associated with severe headaches.

CONCLUSIONS

Our study found no association between severe anesthesia/paresthesia and seasonal influenza vaccination. While there was an association with severe headaches as an adverse event following influenza vaccination, the rates of these events are similar to rates reported from clinical trials and are not a cause for additional concern.