Safety and efficacy of anti-BCMA CAR-T cell therapy in older adults with multiple myeloma: A systematic review and meta-analysis

INTRODUCTION

Anti-B-cell maturation antigen (BCMA) chimeric antigen receptor T-cell (CAR-T) therapy is transforming the care of patients with relapsed/refractory multiple myeloma (MM). Unfortunately, despite being a disease of older adults these patients remain under-represented in most pivotal clinical trials. We performed a systematic review and proportion meta-analysis of prospective clinical trials and observational studies of anti-BCMA CAR-T therapy in patients with MM with the aim to determine the efficacy and safety of this therapy in older adults (≥65 years).

MATERIALS AND METHODS

We searched the Pubmed, Scopus, Web of Science (WOS), Ovid, Embase, CENTRAL, and CINAHL databases through September 9, 2022 and abstracts from the American Society of Hematology (ASH) Annual Meeting 2022. Primary outcome measures included overall response rate (ORR), rates of cytokine release syndrome (CRS), and immune cell-effector-associated neurotoxicity syndrome (ICANS). study was registered with PROSPERO (study number: CRD42022334287).

RESULTS

After screening 2218 references, 14 studies were included for data extraction, with a total of 558 patients, 26.2% (n = 146) of whom were older adults. The pooled ORR amongst this population was 93%, which was comparable to the ORR of 86% amongst younger patients. In older adults, the rates of CRS (any grade) and grade ≥ 3 were 95% and 21%, respectively. For younger patients, the pooled rate of CRS (any grade) and grade ≥ 3 CRS was 91% and 20%, respectively. The rate of ICANS (any grade) in older adults was 15%, which was higher than that observed in those <65 years.

CONCLUSION

Older adults experience comparable outcomes to younger patients with anti-BCMA CAR-T therapy, albeit with numerically higher rates of neurotoxicity.

Simple Score of Albumin and CRP Predicts High-Grade Toxicity in Patients with Multiple Myeloma Receiving CAR-T Therapy

Administration of chimeric-antigen receptor T-cell (CAR-T) therapy is complex and associated with unique toxicities. Identifying patients at risk for inferior outcomes is important for individualized management. The Glasgow-prognostic score (GPS) is a simple score shown to be highly prognostic of outcomes in the setting of traditional chemotherapy or checkpoint inhibitor administration. We sought to evaluate the value of the GPS to predict outcomes of patients with relapse refractory multiple myeloma (RRMM) receiving anti-BCMA CAR-T therapy. We included all patients treated with commercial CAR-T therapy for RRMM between 5/1/2021 and 2/1/2023 at the Moffitt Cancer Center. The GPS (CRP >1 mg/dL, 1 point; albumin <3.5, 1 point) was calculated for all patients at lymphodepletion (day -6) and patients were grouped as high-risk GPS (score = 2) or low-risk GPS (0 or 1). The primary endpoint was overall survival (OS) at day 100. A total of 139 pts were included, with a median follow-up of 6.7 months (95% CI, 6.2 to 8.9 months). Pts were treated with either idecabtagene vicleucel (83%) or ciltacabtagene autoleucel (17%). In total, 14% were classified with high-risk GPS, with significantly increased risk for grade 3 cytokine release syndrome (P = .003) and ICANS of any grade (P < .001). Patients in the high-risk GPS group had significantly lower day-100 OS (68.4% versus 97.3%, P < .001), OS at 6 months (56% versus 91.8% P = .0019) and PFS at 6 months (38.3% versus 72.3%, P = .03). The association of GPS with day-100 OS remained significant in a multivariable model. In conclusion, the GPS identifies a group of high-risk patients with RRMM receiving CAR-T therapy who experience increased rates of immune-mediated toxicity and are at higher risk for early mortality.

Cardiac events after standard of care idecabtagene vicleucel for relapsed and refractory multiple myeloma

Idecabtagene vicleucel (ide-cel) is a type of B-cell maturation antigen (BCMA)-targeting chimeric antigen receptor T-cell (CAR-T) approved for the treatment of relapsed and refractory multiple myeloma (RRMM). Currently, the incidence of cardiac events associated with ide-cel remains unclear. This was a retrospective single-center observational study of patients treated with ide-cel for RRMM. We included all consecutive patients who received standard-of-care ide-cel treatment at least 1-month follow-up. Baseline clinical risk factors, safety profile, and responses were examined based on the development of a cardiac event. A total of 78 patients were treated with ide-cel, and 11 patients (14.1%) developed cardiac events: heart failure (5.1%), atrial fibrillation (10.3%), nonsustained ventricular tachycardia (3.8%), and cardiovascular death (1.3%). Only 11 of the 78 patients had repeat echocardiogram. Baseline risk factors associated with the development of cardiac events included being female sex and having poor performance status, λ light-chain disease, and advanced Revised International Staging System stage. Baseline cardiac characteristics were not associated with cardiac events. During index hospitalization after CAR-T, higher-grade (≥grade 2) cytokine release syndrome (CRS) and immune cell-associated neurologic syndrome were associated with cardiac events. In multivariable analyses, the hazard ratio for the association of the presence of cardiac events with overall survival (OS) was 2.66 and progression-free survival (PFS) was 1.98. Ide-cel CAR-T for RRMM was associated with similar cardiac events as other types of CAR-T. Worse baseline performance status and higher-grade CRS and neurotoxicity were associated with cardiac events after BCMA-directed CAR-T-cell therapy. Our results suggest that the presence of cardiac events may confer worse PFS or OS; although because of the small sample size, the power to detect an association was limited.

Postprandial glycemia in healthy subjects: Which probiotic dairy food is more adequate?

The consumption of probiotic-enriched dairy products has been associated with many health benefits, including anti-hyperglycemic activity. The effect on health is dependent on the type of probiotic culture used and the dairy product consumed. This study evaluated the effect of different probiotic-enriched dairy matrices (Minas Frescal cheese, Prato cheese, and whey dairy beverage) containing Lactobacillus casei on in vitro and in vivo anti-hyperglycemic activity. For this purpose, in vitro anti-hyperglycemic activity was determined by the inhibition of α-glucosidase and α-amylase activities, and a human study was performed with healthy individuals (n = 15, consumption of bread as a control; bread + Minas Frescal cheese; bread + Prato cheese; bread + dairy beverage) to assess the effects of different probiotic foods on postprandial glycemia. In vitro data showed that Prato cheese presented the highest lipid (36.9 g/100 g) and protein (26.5 g/100 g) contents as well as the highest α-amylase (60.7%) and α-glucosidase (52.6%) inhibition. The consumption of Prato cheese resulted in a lesser increase in blood glucose level (13 mg/dL) compared with the consumption of bread alone (19 mg/dL), Minas Frescal cheese (20 mg/dL), and whey dairy beverage (30 mg/dL), with glycemic indices similar to that observed for the control. The present results demonstrated a good correlation between in vitro and in vivo data, in which the type of dairy matrix affects the anti-hyperglycemic activity. It is concluded that the consumption of probiotic Prato cheese can contribute to the reduction of postprandial glycemia in healthy individuals.

Effects of different sources of Saccharomyces cerevisiae biomass on milk production, composition, and aflatoxin M1 excretion in milk from dairy cows fed aflatoxin B1

The aim of the present study was to evaluate the effect of different sources of Saccharomyces cerevisiae (SC) biomass (20.0 g/d) obtained from sugarcane (cell wall, CW; dried yeast, DY; autolyzed yeast, AY) and the beer industry (partially dehydrated brewery yeast, BY) on milk production, fat and protein percentages, and aflatoxin M₁ (AFM₁) excretion in milk from dairy cows receiving 480 µg aflatoxin B₁ (AFB₁) per day. A completely randomized design was used with 2 lactating cows assigned to each of 10 dietary treatments, as follows: negative controls (no AFB₁ or SC-based biomass), positive controls (AFB₁ alone), DY alone, DY + AFB₁, BY alone, BY + AFB₁, CW alone, CW + AFB₁, AY alone, and AY + AFB₁. The cows in the aflatoxin treatment group received AFB₁ from d 1 to 6, while the SC biomass was administered with the AFB₁ bolus from d 4 to 6. Aflatoxin B₁ or SC-based products did not affect milk production or milk composition during the experimental period. Aflatoxin M₁ was detected in the milk from all aflatoxin treatment group cows, reaching maximum levels at d 3 and varying from 0.52 ± 0.03 to 1.00 ± 0.04 µg/L. At end of the treatment period, CW, AY, DY, and BY removed 78%, 89%, 45%, and 50% of AFM₁ from the milk, respectively, based on the highest level found on d 3. Results indicate a potential application of industrial fermentation by-products, especially CW and AY, as a feed additive in the diets of dairy cows to reduce the excretion of AFM₁ in milk.

Assessing the effects of different prebiotic dietary oligosaccharides in sheep milk ice cream

The objective of this study was to assess the effects of different prebiotic dietary oligosaccharides (inulin, fructo-oligosaccharide, galacto-oligossacaride, short-chain fructo-oligosaccharide, resistant starch, corn dietary oligosaccharide and polydextrose) in non-fat sheep milk ice cream processing through physical parameters, water mobility and thermal analysis. Overall, the fat replacement by dietary prebiotic oligosaccharides significantly decreased the melting time, melting temperature and the fraction and relaxation time for fat and bound water (T₂₂) while increased the white intensity and glass transition temperature. The replacement of sheep milk fat by prebiotics in sheep milk ice cream constitutes an interesting option to enhance nutritional aspects and develop a functional food.

Assessment of antioxidant activity, lipid profile, general biochemical and immune system responses of Wistar rats fed with dairy dessert containing Lactobacillus acidophilus La-5

The viability and survival of Lactobacillus acidophilus La5 under in vitro simulated gastrointestinal in probiotic dairy dessert was assessed. In addition, the effects of regular consumption of the dessert (5g/day) on the lipid profile, immune system, and antioxidant/biochemical status of Wistar rats were also evaluated after 2weeks of treatment. Adequate counts of L. acidophilus La-5 were observed regards the viability and gastrointestinal conditions. The probiotic dairy dessert was efficient in reducing the LDL-cholesterol, triacylglycerol and increased the HDL-cholesterol in serum. Aspartate amino transferase, alanine aminotransferase, total protein, albumin, heat shock proteins, immune system responses, and blood-cells counts (monocyte, lymphocyte, neutrophil and leucocyte) were not affected (p>0.05) after 15days of treatment. Overall, the probiotic dairy dessert may be a viable alternative to enhance the blood lipid profile and could be used to improve the antioxidant defenses.

Effect of peracetic acid on biofilms formed by Staphylococcus aureus and Listeria monocytogenes isolated from dairy plants

This research investigated the removal of adherent cells of 4 strains of Staphylococcus aureus and 1 Listeria monocytogenes strain (previously isolated from dairy plants) from polystyrene microtiter plates using peracetic acid (PAA, 0.5%) for 15, 30, 60, and 120 s, and the inactivation of biofilms formed by those strains on stainless steel coupons using the same treatment times. In the microtiter plates, PAA removed all S. aureus at 15 s compared with control (no PAA treatment). However, L. monocytogenes biofilm was not affected by any PAA treatment. On the stainless steel surface, epifluorescence microscopy using LIVE/DEAD staining (BacLight, Molecular Probes/Thermo Fisher Scientific, Eugene, OR) showed that all strains were damaged within 15 s, with almost 100% of cells inactivated after 30 s. Results of this trial indicate that, although PAA was able to inactivate both S. aureus and L. monocytogenes monospecies biofilms on stainless steel, it was only able to remove adherent cells of S. aureus from polystyrene microplates. The correct use of PAA is critical for eliminating biofilms formed by S. aureus strains found in dairy plants, although further studies are necessary to determine the optimal PAA treatment for removing biofilms of L. monocytogenes.

Short communication: Influence of long-chain inulin and Lactobacillus paracasei subspecies paracasei on the sensory profile and acceptance of a traditional yogurt

The objectives of this study were to evaluate the influence of the addition of long-chain inulin as a fat replacer and prebiotic agent (20g/L) and (or) probiotic Lactobacillus paracasei ssp. paracasei on the sensory profile and acceptance of yogurts, and to assess the influence of descriptive attributes on the sensory acceptance of the products. The addition of inulin to low-fat yogurt improved its brightness and firmness, which was similar to the full-fat yogurt. However, the use of long-chain inulin increased the separation of serum and no influence on creaminess was observed. Regarding the product's acceptability, the low-fat yogurt with added inulin presented similar acceptance compared with the full-fat yogurt. The addition of Lb. paracasei ssp. paracasei did not affect the sensory profile and acceptance of the low-fat yogurt. Using external preference mapping, it was possible to verify that the sensory acceptance was driven positively by the sweetness and creaminess and negatively driven by firmness (appearance and texture) and homogeneity (appearance). It was possible to formulate low-fat yogurts with added probiotics that presented similar sensory characteristics to those of full-fat yogurts, and this was due to the addition of the long-chain inulin as a fat replacer.

Probiotic cheese attenuates exercise-induced immune suppression in Wistar rats

Intense physical activity results in a substantial volume of stress and hence a significant probability of immunosuppression in athletes, with milk proteins being, perhaps, the most recommended protein supplements. Consumption of a probiotic cheese can attenuate immune suppression induced by exhausting exercise in rats. A popular Brazilian fresh cheese (Minas Frescal cheese) containing Lactobacillus acidophilus LA14 and Bifidobacterium longum BL05 was fed for 2wk to adult Wistar rats, which then were brought to exhaustion on the treadmill. Two hours after exhaustion, the rats were killed and material was collected for the determination of serum uric acid, total and high-density lipoprotein cholesterol fraction, total protein, triacylglycerols, aspartate aminotransferase, alanine aminotransferase, creatine kinase, and blood cell (monocyte, lymphocyte, neutrophil, and leukocyte) counts. Exercise was efficient in reducing lymphocyte counts, irrespective of the type of ingested cheese, but the decrease in the group fed the probiotic cheese was 22% compared with 48% in the animals fed regular cheese. Monocyte counts were unaltered in the rats fed probiotic cheese compared with a significant decrease in the rats fed the regular cheese. Most importantly, ingestion of the probiotic cheese resulted in a >100% increase in serum high-density lipoprotein cholesterol and a 50% decrease in triacylglycerols. We conclude that probiotic Minas Frescal cheese may be a viable alternative to enhance the immune system and could be used to prevent infections, particularly those related to the physical overexertion of athletes.

Probiotic yogurts manufactured with increased glucose oxidase levels: postacidification, proteolytic patterns, survival of probiotic microorganisms, production of organic acid and aroma compounds

We investigated the effect of increased glucose oxidase concentration as a technological option to decrease oxidative stress during the processing of probiotic yogurts. Probiotic yogurts were produced with increased concentrations of glucose oxidase (0, 250, 500, 750, or 1,000 mg/kg) and submitted to physicochemical and microbiological analysis at 1, 15, and 30 d of refrigerated storage. Higher concentrations of glucose oxidase (750 and 1,000 mg/kg) and a longer storage time were found to have an influence on the characteristics of the probiotic yogurt, contributing to more extensive postacidification, an increase in the dissolved oxygen level, and higher proteolysis. In addition, increased production of aroma compounds (diacetyl and acetaldehyde) and organic acids (mainly lactic acid) and a decrease in the probiotic bacteria count were reported. The use of glucose oxidase was a feasible option to minimize oxidative stress in probiotic yogurts. However, supplementation with excessive amounts of the enzyme may be ineffective, because insufficient substrate (glucose) is present for its action. Consumer tests should be performed to evaluate changes in the sensory attributes of the probiotic yogurts with increased supplementation of glucose oxidase. In addition, packaging systems with different permeability to oxygen should be evaluated.

Effect of the inoculation level of Lactobacillus acidophilus in probiotic cheese on the physicochemical features and sensory performance compared with commercial cheeses

The complex metabolism of probiotic bacteria requires several technological options to guarantee the functionally of probiotic dairy foods during the shelf life. This research aimed to evaluate the effect of the supplementation of increasing amounts of Lactobacillus acidophilus (0, 0.4, or 0.8 g/L of milk) on the physicochemical parameters and sensory acceptance of Minas fresh cheese. In addition, the sensory acceptance of probiotic cheeses was assessed using a consumer test and compared with commercial cheeses (conventional and probiotic). High counts (9.11 to 9.42 log cfu/g) of L. acidophilus were observed throughout the shelf life, which contributed to the maintenance of its probiotic status and resulted in lower pH values and greater production of organic acids. The probiotic cheeses presented lower scores for appearance, aroma, and texture compared with conventional cheeses. Internal preference mapping explained almost 60% of the total variation of the data and showed a large number of consumers concentrated near the conventional cheeses, demonstrating greater preference for these samples. The findings indicated that some negative sensory effects could occur when high level of supplementation with L. acidophilus is used in probiotic cheese processing.

Processing optimization of probiotic yogurt containing glucose oxidase using response surface methodology

Exposure to oxygen may induce a lack of functionality of probiotic dairy foods because the anaerobic metabolism of probiotic bacteria compromises during storage the maintenance of their viability to provide benefits to consumer health. Glucose oxidase can constitute a potential alternative to increase the survival of probiotic bacteria in yogurt because it consumes the oxygen permeating to the inside of the pot during storage, thus making it possible to avoid the use of chemical additives. This research aimed to optimize the processing of probiotic yogurt supplemented with glucose oxidase using response surface methodology and to determine the levels of glucose and glucose oxidase that minimize the concentration of dissolved oxygen and maximize the Bifidobacterium longum count by the desirability function. Response surface methodology mathematical models adequately described the process, with adjusted determination coefficients of 83% for the oxygen and 94% for the B. longum. Linear and quadratic effects of the glucose oxidase were reported for the oxygen model, whereas for the B. longum count model an influence of the glucose oxidase at the linear level was observed followed by the quadratic influence of glucose and quadratic effect of glucose oxidase. The desirability function indicated that 62.32 ppm of glucose oxidase and 4.35 ppm of glucose was the best combination of these components for optimization of probiotic yogurt processing. An additional validation experiment was performed and results showed acceptable error between the predicted and experimental results.

[Outbreak of histoplasmosis in Pedro Leopoldo, Minas Gerais, Brazil]

An outbreak of histoplasmosis was spotted in Pedro Leopoldo, a city in Minas Gerais State, Brazil, in 1997, where four individuals had been in contact with a bat-inhabited cave. Acute pulmonary histoplasmosis diagnosis was made by the use of clinical, serologic, radiographic and epidemiological criteria. An antifungal treatment with ketoconazole (400mg daily for 30 days) was administered resulting in symptons' remission in a few days.

[Functional disorders of Oddi's sphincter]

The sphincter of Oddi (SO), located at a crucial anatomical site, continues to present diagnostic and therapeutic problems. A combination of the techniques of endoscopic retrograde cholangiopancreatography and manometry has permitted direct assessment of the SO function, and has opened up a new era in the study of this structure.

Side-to-side choledochoduodenostomy in the management of choledocholithiasis and associated disease. Facts and fiction

Ascending cholangitis, the sump syndrome, and alkaline reflux gastritis are drawbacks commonly ascribed to side-to-side choledochoduodenostomy. Most surgeons consider side-to-side choledochoduodenostomy as a last resort measure to be utilized only in elderly patients and only on ducts wider than 15 mm. In trying to assess the pertinence of such alleged inconveniences and limitations, a series has been analyzed (retrospectively until 1976 and prospectively from then on). A total of 70 of these operations were performed from January 1973 to September 1982, on 53 women and 17 men. Twenty-six percent were less than 50 years of age, and 30 percent were over 70 years of age. Sixteen of the 70 operations were reoperations that took place several years after cholecystectomy. Intravenous cholangiographic films were obtained preoperatively for evaluation of the duct width which was less than 15 mm in 23 patients (33 percent). The follow-up period, surpassing 2 years in 35 patients (50 percent), includes clinical interviews and liver biochemistry measurements every 6 months, and endoscopic retrograde cholangiopancreatography 12 to 18 months postoperatively. There was one postoperative death (1.4 percent), and significant morbidity developed in five patients (7.1 percent). The postoperative hospital stay averaged 8 days. The long-term results were classified as excellent in 50 patients, good in 15 patients, fair in 3 patients, and poor in 1 patient. Side-to-side choledochoduodenostomy is a safe, very effective therapeutic measure, even when performed on ducts less than 15 mm wide, provided a few technical requirements are respected. It does not carry the inconveniences that have usually been ascribed to it. The excellent long-term results in the present series have allowed us to liberalize its utilization, especially in young patients.

Endoscopy in the upper G.I. bleedings

From 388 patients with upper G.I. bleeding investigated by endoscopy, radiology or emergent surgery, one third bled from duodenal ulcer, one third oesophageal varices, and from the remain the most frequent were gastric ulcer (14%) and gastric cancer (9%). From a sample of 53 patients with liver cirrhosis, 66% bled from varices and 34% from other lesions. The proportion of patients who bled from oesophageal varices is higher under 60 yrs. The mortality was higher after 60 yrs, except when there was associated chronic liver disease or renal or cardio-respiratory failure. In this group of patients, near half in our series, the mortality is the same under and above 60 years.