Hyperinflammatory syndrome resembling haemophagocytic lymphohistiocytosis following axicabtagene ciloleucel and brexucabtagene autoleucel

Haemophagocytic lymphohistiocytosis-like toxicity following chimeric antigen receptor T cells (CAR-HLH) is being increasingly recognized, while published data are limited and criteria for recognition are elusive. We describe three patients who developed CAR-HLH after infusion of brexucabtagene autoleucel (n = 2) or axicabtagene ciloleucel (n = 1). All three patients presented following cytokine release syndrome, with fever, recurrent or worsening cytopenias, hyperferritinaemia, elevated soluble interleukin (IL)-2 receptor, hypofibrinogenaemia, hypertriglyceridaemia, elevated liver transaminases, and decreasing C-reactive protein and IL-6. Clinical improvement following treatment with anakinra (n = 2) and ruxolitinib (n = 1) was observed. Our report offers an opportunity for prompt recognition and initiation of potentially life-saving treatment for CAR-HLH.

Development of a Statewide Antibiogram to Assess Regional Trends in Antibiotic-Resistant ESKAPE Organisms

Background:

Hospitals and other facilities utilize antibiograms as tools for optimal antibiotic selection. Currently, no measures compare broad trends on the regional level, despite interest for more comprehensive data, particularly for antibiotic-resistant ESKAPE organisms.

Objective:

To collect and compare regional health-care facility antibiogram data for ESKAPE organisms to form a cumulative antibiogram.

Methods:

Health-care facilities were identified using the publicly accessible Pennsylvania Department of Health web site. Facilities were contacted by phone from June 2015 to 2016 to ascertain participation/consent for the study. An electronic questionnaire ascertained baseline facility characteristics. Facilities provided quantitative antibiotic susceptibility data via antibiograms. Antibiogram data were synthesized as cumulative susceptibilities, stratified by urban/suburban versus rural location.

Results:

Forty-five facilities were included in the study (n = 18 urban/suburban, n = 27 rural). The overall prevalence of methicillin-resistant S aureus was 41.5%, stratified at 40.6% and 43.3% in urban/suburban and rural facilities, respectively ( P < .001). Vancomycin-resistant Enterococcus prevalence was 18.8% overall, with 27.7% in urban/suburban and 14.0% in rural facilities ( P < .001). Generally, lower susceptibility rates were found for high-utilization beta-lactams across gram-negative organisms in urban/suburban facilities.

Conclusions:

Development of a regional cumulative antibiogram that targets key ESKAPE pathogens is feasible, while observed trends may help aid future antimicrobial stewardship efforts.

Delivery systems for BMPs: factors contributing to protein retention at an application site

BACKGROUND

Recombinant human bone morphogenetic proteins (rhBMPs) are being tested in clinical studies for their capacity to elicit bone formation. Biomaterials used in delivery systems also play a critical role in supporting the osteoinductive activity of BMPs, attributable to the controlled presentation of the BMPs to target cells. Despite extensive preclinical studies, the factors contributing to local rhBMP pharmacokinetics remain to be elucidated.

METHODS

The rhBMP pharmacokinetics were studied in a rat subcutaneous implant and in an intramuscular injection model. In situ levels of rhBMPs were quantitated with use of 125I-labeled tracers. The effects of protein structural features and the nature of the biomaterial implant were explored. Osteoinduction by biomaterial+rhBMP combinations was assessed by a semiquantitative, histology-based bone score.

RESULTS

With the use of rhBMP-2, rhBMP-4, and an N-truncated rhBMP-2, the protein isoelectric point was found critical for the initial retention of rhBMPs in an implant. Osteoinduction studies carried out in parallel indicated that rhBMPs with a higher implant retention elicited more bone formation. In the clinically used collagen+rhBMP-2 device, collagen crosslinking and sterilization were most influential in rhBMP-2 retention. To increase retention at an application site, thermoreversible polymers were engineered and shown to enhance local rhBMP-2 retention, especially by injectable delivery.

CONCLUSIONS

Two critical components of an osteoinductive device--namely, the biomaterial and the rhBMP--were shown to influence local protein pharmacokinetics and osteoinductive activity of the device. Designer biomaterials can provide an additional mechanism to modulate local protein pharmacokinetics.

CLINICAL RELEVANCE

These studies form the foundation of next-generation osteoinductive devices with improved potency at sites of desired bone regeneration and reduced side effects at other sites.

Purification and characterization of choline/ethanolamine kinase from rat liver

Choline kinase, the first enzyme in the CDP-choline pathway for phosphatidylcholine biosynthesis, was purified 26,000-fold from rat liver to a specific activity of 143,000 nmol.min-1.mg-1 protein. The subunit molecular mass was 47 kDa by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, while the apparent native molecular mass was 160 kDa by size exclusion chromatography, suggesting a tetrameric structure. Two peaks of choline kinase activity were obtained by chromatofocusing. These isoforms eluted at pH 4.7 (CKI) and 4.5 (CKII). CKII appeared to be homogeneous by sodium dodecyl sulfate gel electrophoresis. Peptide mapping of two isoforms indicated a high degree of similarity, although there were peptides not common to both. Ethanolamine kinase activity copurified with both isoforms. The ratio of choline to ethanolamine kinase activity was 3.7 +/- 0.7 throughout the purification procedure. Choline and ethanolamine were mutually competitive inhibitors. The respective Km values, 0.013 and 1.2 mM, were similar to the Ki values of 0.014 and 2.2 mM. An antibody raised against CKII immunoprecipitated both choline and ethanolamine kinase activities from liver cytosol at the same titer. These data suggest that both activities reside on the same protein and occur at the same active site. Similarly, both activities were immunoprecipitated from brain, lung, and kidney cytosols. Western blot analysis showed both purified liver isoforms, as well as brain, lung and kidney enzymes, to have a molecular mass of 47 kDa.

The effect of polycyclic aromatic hydrocarbons on choline kinase activity in mouse hepatoma cells

Choline kinase catalyzes the first rate-limiting step in the pathway of biosynthesis of phosphatidylcholine. This enzyme was shown previously to be induced in liver by treatment of rats with polycyclic aromatic hydrocarbons (Ishidate et al. (1980) Biochem. Biophys. Res. Commun. 96, 946-952). The present study was undertaken to determine whether choline kinase in the murine hepatoma cell line, Hepa 1c1c7, is inducible by aromatic hydrocarbons and, if so, whether this induction is mediated by the aromatic hydrocarbon receptor. Treatment of Hepa 1c1c7 cells with 10 microM beta-naphthoflavone resulted in a 1.6-fold increase of choline kinase activity, but no response was seen when the cells were exposed to either 5.0 microM benzo[a]pyrene or 1.0 nM 2.3,7,8-tetrachlorodibenzo-p-doxin, both potent inducers of aryl hydrocarbon hydroxylase. Cell line variants with either deficient or elevated aromatic hydrocarbon receptors showed no increase in choline kinase activity following treatment with any of the polycyclic aromatic hydrocarbons. These results are not consistent with a role for the aromatic hydrocarbon receptor in increased choline kinase activity in Hepa 1c1c7 cells.