Simultaneous targeting of B-cell malignancies and human immunodeficiency virus with bispecific chimeric antigen receptor T cells

Not available.

Dexamethasone potentiates chimeric antigen receptor T cell persistence and function by enhancing IL-7Rα expression

Dexamethasone (dex) is a glucocorticoid that is a mainstay for the treatment of inflammatory pathologies, including immunotherapy-associated toxicities, yet the specific impact of dex on the activity of CAR T cells is not fully understood. We assessed whether dex treatment given ex vivo or as an adjuvant in vivo with CAR T cells impacted the phenotype or function of CAR T cells. We demonstrated that CAR T cell expansion and function were not inhibited by dex. We confirmed this observation using multiple CAR constructs and tumor models, suggesting that this is a general phenomenon. Moreover, we determined that dex upregulated interleukin-7 receptor α on CAR T cells and increased the expression of genes involved in activation, migration, and persistence when supplemented ex vivo. Direct delivery of dex and IL-7 into tumor-bearing mice resulted in increased persistence of adoptively transferred CAR T cells and complete tumor regression. Overall, our studies provide insight into the use of dex to enhance CAR T cell therapy and represent potential novel strategies for augmenting CAR T cell function during production as well as following infusion into patients.

Myeloid lineage switch following CD7-targeted chimeric antigen receptor T-cell therapy in relapsed/refractory T-cell acute lymphoblastic leukemia

Not available.

Favorable Activity and Safety Profile of Memory-Enriched CD19-Targeted Chimeric Antigen Receptor T-Cell Therapy in Adults with High-Risk Relapsed/Refractory ALL

PURPOSE

A phase I/II study evaluating the safety and activity of memory-enriched CD19-directed chimeric antigen receptor (CD19-CAR) T cells in adults with relapsed/refractory B-cell acute lymphoblastic leukemia (ALL).

PATIENTS AND METHODS

In phase I, we tested sequentially two cell populations for CAR transduction: (i) central memory (Tcm) or (ii) naïve, stem, and central memory (Tn/mem) T cells. The study employed an activity constrained for toxicity design to determine the recommended phase II dose (RP2D), which was tested in phase II.

RESULTS

The Tcm cohort was closed early due to lack of activity. The 200 ×106 Tn/mem-derived CD19-CAR T-cell dose was found to be safe and active, and was declared the RP2D. At RP2D, 58 participants underwent leukapheresis and 46 received CD19-CAR T cells. Median age for treated participants was 38 years (range, 22-72). Twenty-nine (63%) participants had relapsed post-allogeneic hematopoietic cell transplantation (alloHCT), 18 (39%) had Philadelphia-like (Ph-like) genotype, and 16 (35%) had extramedullary disease (EMD) at lymphodepletion (LD). Three (7%) participants had grade 3 cytokine release syndrome (CRS), and none had grade ≥ 4 CRS. Eight (17%) participants had grade ≥ 3 neurotoxicity, including one fatal cerebral edema. Forty (87%) patients achieved complete remission (CR)/CR with incomplete hematologic recovery, 2 (4%) progressed, and 4 (9%) were unevaluable for response. Among 42 response-evaluable participants, 16/17 with Ph-like ALL and 13/15 with EMD at LD responded. Twenty-one (53%) responders underwent alloHCT consolidation, which was associated with improved relapse-free survival (adjusted HR = 0.16; 95% confidence interval, 0.05-0.48; P = 0.001).

CONCLUSIONS

Tn/mem-derived CD19-CAR T cells were safe and active, including in Ph-like ALL and EMD. See related commentary by El Marabti and Abdel-Wahab, p. 694.

CD19/BAFF-R dual-targeted CAR T cells for the treatment of mixed antigen-negative variants of acute lymphoblastic leukemia

Chimeric antigen receptor (CAR) T cells targeting CD19 mediate potent antitumor effects in B-cell malignancies including acute lymphoblastic leukemia (ALL), but antigen loss remains the major cause of treatment failure. To mitigate antigen escape and potentially improve the durability of remission, we developed a dual-targeting approach using an optimized, bispecific CAR construct that targets both CD19 and BAFF-R. CD19/BAFF-R dual CAR T cells exhibited antigen-specific cytokine release, degranulation, and cytotoxicity against both CD19-/- and BAFF-R-/- variant human ALL cells in vitro. Immunodeficient mice engrafted with mixed CD19-/- and BAFF-R-/- variant ALL cells and treated with a single dose of CD19/BAFF-R dual CAR T cells experienced complete eradication of both CD19-/- and BAFF-R-/- ALL variants, whereas mice treated with monospecific CD19 or BAFF-R CAR T cells succumbed to outgrowths of CD19-/BAFF-R+ or CD19+/BAFF-R- tumors, respectively. Further, CD19/BAFF-R dual CAR T cells showed prolonged in vivo persistence, raising the possibility that these cells may have the potential to promote durable remissions. Together, our data support clinical translation of BAFF-R/CD19 dual CAR T cells to treat ALL.

Large-scale manufacturing and characterization of CMV-CD19CAR T cells

BACKGROUND

Adoptive transfer of CD19-specific chimeric antigen receptor (CD19CAR) T cells can induce dramatic disease regression in patients with B cell malignancies. CD19CAR T cell therapy may be limited by insufficient engraftment and persistence, resulting in tumor relapse. We previously demonstrated a proof of principle that cytomegalovirus (CMV)-specific T cells can be isolated and enriched prior to CD19CAR transduction to produce CMV-CD19CAR T cells, and that these CMV-CD19CAR T cells can be expanded in vivo through CMV vaccination, resulting in better tumor control in a murine model. Here we developed a clinical platform for generating CMV-CD19CAR T cells.

METHODS

Peripheral blood mononuclear cells (PBMCs) collected from CMV-seropositive healthy donors were stimulated with a good manufacturing practices-grade PepTivator overlapping CMVpp65 peptide pool and enriched for CMV-responsive interferon γ (IFNγ)+T cells using IFNγ Catchmatrix, within the CliniMACS Prodigy Cytokine Capture System (Miltenyi Biotec). Resulting CMV-specific T cells were transduced with a lentiviral vector encoding a second generation CD19R:CD28:ζ/EGFRt CAR and expanded with interleukin 2 (IL-2) and IL-15 for 15 days before characterization.

RESULTS

CMV-specific T cells were enriched from 0.8%±0.5 of input PBMC to 76.3%±11.6 in nine full-scale qualification runs (absolute yield of 4.2±3.3×10⁶ IFNγ+T cells from an input of 1×10⁹ PBMCs). Average CD19CAR transduction efficiency of CMV-specific T cells was 27.0%±14.2 in the final products, which underwent rapid expansion, resulting in a total cell dose of 6.2±0.9 × 10⁶ CD19CAR-tranduced T cells with CMV specificity (ie, functionally bispecific). CMV-CD19CAR T cells were polyclonal, expressed memory markers but had low expression of exhaustion markers, responded to both CD19 and CMVpp65 stimulation with rapid proliferation and exhibited antigen-specific effector functions against both CD19-expressing tumors and CMVpp65 antigen. The final products passed release criteria for clinical use.

CONCLUSIONS

We demonstrated the feasibility of our large-scale platform for generating CMV-CD19CAR T cells for clinical application. We plan to initiate a clinical trial at City of Hope using CMV-CD19CAR T cells for patients with intermediate/high-grade B cell non-Hodgkin's lymphoma immediately after autologous hematopoietic cell transplantation followed by vaccination with a novel CMV vaccine based on Modified Vaccinia Ankara (Triplex) 28 days and 56 days post-T cell infusion.

Cytokine Release Syndrome Following Peripheral Blood Stem Cell Haploidentical Hematopoietic Cell Transplantation with Post-Transplantation Cyclophosphamide

Post-transplantation cyclophosphamide (PTCy) is a safe and efficacious graft-versus-host-disease (GVHD) prophylaxis following hematopoietic cell transplantation (HCT) from a haploidentical (haplo) donor. Cytokine release syndrome (CRS) is a common complication of this platform. Early fever post-haplo-HCT using bone marrow grafts is associated with higher CD3⁺ cell dose and CRS. However, the impact of CD3⁺ and CD34⁺ cell dose on CRS post-haplo-HCT using peripheral blood stem cell (PBSC) grafts is unknown. Our goals were to evaluate the incidence of CRS following PBSC transplantation (PBSCT) and to identify factors that can be modified to prevent the development of severe CRS in this setting. In 271 patients, we investigated factors associated with the development of CRS following haplo-PBSCT and examined the impact of CRS on clinical outcomes. Ninety-three percent of the patients developed CRS of any grade post-haplo-PBSCT. In multivariate analysis, severe CRS (grade 3-4 versus grade 0-1) was associated with higher nonrelapse mortality (hazard ratio [HR], 6.42; 95% confidence interval [CI], 2.68 to 15.39; P < .001), worse 1-year overall survival (HR, 3.40; 95% CI, 1.63 to 7.08; P = .005), and worse disease-free survival (HR, 4.02; 95% CI, 1.99 to 8.08; P < .001). Moderate to severe CRS (grade 2-4) did not impact 1-year relapse or acute GVHD (grade II-IV and III-IV) at 100 days (P = .71 and .19, respectively). Importantly, higher CD3⁺ cell dose, but not CD34⁺ cell dose, predicted a higher incidence of grade 2-4 CRS (HR, 1.20; 95% CI,1.07 to 1.36; P = .003) and grade 3-4 CRS (HR, 1.40; 95% CI, 1.05 to 1.86; P = .022). Both older age (HR, 8.57; 95% CI, 1.73 to 42.36; P < .001) and non-total body irradiation-based reduced-intensity conditioning with fludarabine/melphalan (HR, 15.38; 955 CI, 2.06 to 114.67; P < .001) were predictive of grade 3-4 CRS. Overall, we observed that severe CRS (grade 3-4) negatively affected transplantation outcome, and that higher CD3 cell dose was associated with the development of any grade CRS and severe CRS.

Tacrolimus initial steady state level in post-transplant cyclophosphamide-based GvHD prophylaxis regimens

Post-transplant cyclophosphamide (PTCy) combined with tacrolimus (TAC) as graft-versus-host disease (GvHD) prophylaxis post-hematopoietic cell transplantation (HCT) is safe and effective. Optimal serum levels of TAC in this combination remain undetermined. We hypothesized that TAC at initial steady state (TISS) of <10 ng/mL could promote optimal transplant outcomes and prevent TAC-associated toxicities. We retrospectively analyzed a consecutive case series of 210 patients who received PTCy/TAC-based prophylaxis post-HCT from 1/2013–6/2018. Patients received HCT from haploidentical (n=172) or mismatched donors (n=38), and flat dose (FD) or weight-based dose (WBD) TAC. Twenty-four-month overall survival (OS), disease free survival (DFS), and relapse rate (RR) were 61%, 56%, and 22%, respectively, in TISS <10 ng/mL cohort (n=176), and 50%, 43%, and 35%, respectively, in TISS ≥10 ng/mL cohort (n=34) (OS, P=0.71; DFS, P=0.097; RR, P=0.031). OS, DFS, RR, non-relapse mortality, acute GvHD grade II-IV, grade III-IV or chronic GvHD by TISS were similar in multivariable analysis. TISS ≥10 ng/mL conferred increased risk of viral infection (P=0.003). More patients receiving FD vs. WBD had TISS <10 ng/mL (P=0.001). Overall, TISS <10 ng/mL early post HCT conferred similar survival outcomes and lowered risk of viral infection and toxicities compared to TISS ≥10 ng/mL.

CD33 directed bispecific antibodies in acute myeloid leukemia

Despite the approval of a number of new targeted therapies for acute myeloid leukemia (AML), median overall survival still remains poor, ranging from 12 to 18 months in most patients. Based on the success of blinatumomab, the CD19-targeted bispecific antibody for the treatment of acute lymphoblastic leukemia, the development of several CD33-targeted bispecific antibodies for AML are being investigated in clinical trials. In this review article of CD33-targeted bispecific antibodies, we describe the rationale for targeting CD3 x CD33, summarize the data from four ongoing phase 1 studies, review the major toxicity associated with CD33-targeted bispecific antibody therapy of cytokine release syndrome (CRS) and steps to mitigate CRS, and describe possible mechanisms of resistance to CD33-targeted bispecific antibody therapy. Future development to try to improve outcomes include combination therapies to reduce the tumor burden prior to starting treatment, combining with immune checkpoint inhibition therapy such as anti-PD-1/PDL1 antibodies, and the use of second generation bispecific antibodies that target two different antigens and recruit other effector cells such as nature killer cells and macrophages.

The Cerebroventricular Environment Modifies CAR T Cells for Potent Activity against Both Central Nervous System and Systemic Lymphoma

Lymphomas with central nervous system (CNS) involvement confer a worse prognosis than those without CNS involvement, and patients currently have limited treatment options. T cells genetically engineered with CD19-targeted chimeric antigen receptors (CAR) are effective against B-cell malignancies and show tremendous potential in the treatment of systemic lymphoma. We aimed to leverage this strategy toward a more effective therapy for patients with lymphoma with CNS disease. NOD-scid IL2Rgamma^null (NSG) mice with CNS and/or systemic lymphoma were treated with CD19-CAR T cells via intracerebroventricular (ICV) or intravenous (IV) injection. CAR T cells isolated after treatment were rigorously examined for phenotype, gene expression, and function. We observed that CAR T cells infused ICV, but not IV, completely and durably eradicated both CNS and systemic lymphoma. CAR T cells delivered ICV migrated efficiently to the periphery, homed to systemic tumors, and expanded in vivo, leading to complete elimination of disease and resistance to tumor rechallenge. Mechanistic studies indicated that ICV-delivered CAR T cells are conditioned by exposure to cerebrospinal fluid in the ICV environment for superior antilymphoma activity and memory function compared with IV-delivered CAR T cells. Further analysis suggested that manipulating cellular metabolism or preactivating therapeutic CAR T cells with antigen ex vivo may improve the efficacy of CAR T cells in vivo Our demonstration that ICV-delivered CD19-CAR T cells had activity against CNS and systemic lymphoma could offer a valuable new strategy for treatment of B-cell malignancies with CNS involvement.

Developing and Monitoring a Standard-of-Care Chimeric Antigen Receptor (CAR) T Cell Clinical Quality and Regulatory Program

As the world of cellular therapy expands to include immune effector cell (IEC) products such as commercial chimeric antigen receptor (CAR) T cells, quality management (QM) professionals are faced with creating either new IEC stand-alone programs or expand existing hematopoietic cell transplantation (HCT) programs to promote patient safety and be aligned with quality, regulatory, and accreditation requirements. The team professionals at City of Hope (COH) recently expanded the quality HCT program to include IEC products and, in doing so, implemented new regulatory infrastructure while maintaining high quality patient care. At COH, we developed the quality structure of our cellular therapy program through collaborations between quality, regulatory, and CAR T patient care committees, which included physicians and nurse coordinators. To ensure the quality of our program, we monitor data collection and reporting, perform quarterly proactive audits of, for example, outcome analysis, and measure selected end-points for benchmarking purposes. QM professionals play a critical role in the monitoring and evaluation processes and provide guidance on how to implement accreditation requirements and what impact the requirements may have on care management. Here we describe the process by which COH expanded our HCT QM program to include IEC therapy. We share examples of how we developed our overall program structure and other key items such as how we addressed patient care management and accreditation to apprise other programs that wish to create and/or expand existing programs.

The neurogenetics of atypical parkinsonian disorders

Although classic Parkinson disease is the disorder most commonly associated with the clinical feature of parkinsonism, there is in fact a broader spectrum of disease represented by a collection of phenotypically similar neurodegenerative conditions that mimic many of its core features. These atypical parkinsonian disorders most commonly include progressive supranuclear palsy and corticobasal degeneration, disorders both associated with frontotemporal dementia, as well as multiple system atrophy and dementia with Lewy bodies. Although the clinical distinction of these disorders still remains a challenge to physicians, recent advances in genetics are poised to tease apart the differences. Insights into the molecular etiologies underlying these conditions will improve diagnosis, yield a better understanding of the underlying disease pathology, and ultimately lend stimulation to the development of potential treatments. At the same time, the wide range of phenotypes observed from mutations in a single gene warrants broad testing facilitated by advances in DNA sequencing. These expanding genomic approaches, ranging from the use of next-generation sequencing to identify causative or risk-associated gene variations to the study of epigenetic modification linking human genetics to environmental factors, are poised to lead the field into a new age of discovery.

Laparoscopic-assisted removal of gastric trichobezoar; a novel technique to reduce operative complications and time

Trichobezoar complicates trichophagia. It can provide a diagnostic challenge due to the variety of presenting features. Surgical removal is usually required for relief of symptoms and prevention of further complications. We describe 2 cases of gastric trichobezoar, and present a novel laparoscopic-assisted technique of removal of large trichobezoars involving the use of an Alexis wound retractor. This is advantageous as it keeps peritoneal cavity and skin clean and the gastric wound is protected from trauma by repeated instrumentation. Excellent access to the stomach is provided. A larger foramen means the bezoar could be removed quicker than through a port, reducing operative time.

T cells modulate glycans on CD43 and CD45 during development and activation, signal regulation, and survival

Glycosylation affects many essential T cell processes and is intrinsically controlled throughout the lifetime of a T cell. CD43 and CD45 are the two most abundant glycoproteins on the T cell surface and are decorated with O- and N-glycans. Global T cell glycosylation and specific glycosylation of CD43 and CD45 are modulated during thymocyte development and T cell activation; T cells control the type and abundance of glycans decorating CD43 and CD45 by regulating expression of glycosyltransferases and glycosidases. Additionally, T cells regulate glycosylation of CD45 by expressing alternatively spliced isoforms of CD45 that have different glycan attachment sites. The glycophenotype of CD43 and CD45 on T cells influences how T cells interact with the extracellular environment, including how T cells interact with endogenous lectins. This review focuses on changes in glycosylation of CD43 and CD45 occurring throughout T cell development and activation and the role that glycosylation plays in regulating T cell processes, such as migration, T cell receptor signaling, and apoptosis.

HMGB1 mediates endogenous TLR2 activation and brain tumor regression

BACKGROUND

Glioblastoma multiforme (GBM) is the most aggressive primary brain tumor that carries a 5-y survival rate of 5%. Attempts at eliciting a clinically relevant anti-GBM immune response in brain tumor patients have met with limited success, which is due to brain immune privilege, tumor immune evasion, and a paucity of dendritic cells (DCs) within the central nervous system. Herein we uncovered a novel pathway for the activation of an effective anti-GBM immune response mediated by high-mobility-group box 1 (HMGB1), an alarmin protein released from dying tumor cells, which acts as an endogenous ligand for Toll-like receptor 2 (TLR2) signaling on bone marrow-derived GBM-infiltrating DCs.

METHODS AND FINDINGS

Using a combined immunotherapy/conditional cytotoxic approach that utilizes adenoviral vectors (Ad) expressing Fms-like tyrosine kinase 3 ligand (Flt3L) and thymidine kinase (TK) delivered into the tumor mass, we demonstrated that CD4(+) and CD8(+) T cells were required for tumor regression and immunological memory. Increased numbers of bone marrow-derived, tumor-infiltrating myeloid DCs (mDCs) were observed in response to the therapy. Infiltration of mDCs into the GBM, clonal expansion of antitumor T cells, and induction of an effective anti-GBM immune response were TLR2 dependent. We then proceeded to identify the endogenous ligand responsible for TLR2 signaling on tumor-infiltrating mDCs. We demonstrated that HMGB1 was released from dying tumor cells, in response to Ad-TK (+ gancyclovir [GCV]) treatment. Increased levels of HMGB1 were also detected in the serum of tumor-bearing Ad-Flt3L/Ad-TK (+GCV)-treated mice. Specific activation of TLR2 signaling was induced by supernatants from Ad-TK (+GCV)-treated GBM cells; this activation was blocked by glycyrrhizin (a specific HMGB1 inhibitor) or with antibodies to HMGB1. HMGB1 was also released from melanoma, small cell lung carcinoma, and glioma cells treated with radiation or temozolomide. Administration of either glycyrrhizin or anti-HMGB1 immunoglobulins to tumor-bearing Ad-Flt3L and Ad-TK treated mice, abolished therapeutic efficacy, highlighting the critical role played by HMGB1-mediated TLR2 signaling to elicit tumor regression. Therapeutic efficacy of Ad-Flt3L and Ad-TK (+GCV) treatment was demonstrated in a second glioma model and in an intracranial melanoma model with concomitant increases in the levels of circulating HMGB1.

CONCLUSIONS

Our data provide evidence for the molecular and cellular mechanisms that support the rationale for the clinical implementation of antibrain cancer immunotherapies in combination with tumor killing approaches in order to elicit effective antitumor immune responses, and thus, will impact clinical neuro-oncology practice.

Validation of an independent living scale for post-acute rehabilitation applications

The Independent Living Scale (ILS) was developed in a post-acute traumatic brain injury (TBI) rehabilitation facility over a 15-year period to assess three main areas: (1) activities of daily living, (2) behaviour, and (3) initiation. The purpose of this study was to examine the psychometric properties of the ILS, including test--retest stability, construct validity, and statistical fit. Statistical analysis was completed on all weekly scores between the years 1986-1995 (n = 5250). A previous study showed ILS inter-rater reliability to be 0.85 and convergent validity 0.82--0.87. This study demonstrated a test--retest stability of 0.72, the Kaiser-Meyer-Olkin Measure of Sampling Adequacy 0.94 (marvelous), and a Bartlett Test of Sphericity result of 'scale items independent'. The ILS was shown to have good construct validity, inter-rater reliability, internal consistency, instrument stability, and convergent validity.

Women's self-perception and self-care practice: implications for health care delivery

Mexican American women experience unique health care needs related to integration of Mexican and American cultures. To learn how to better promote self-care practices and service utilization in women of Mexican origin living in Texas, researchers used a qualitative approach to interview a convenience sample of 11 low-income women attending a health clinic. Researchers collected narrative data about the women's perceptions of health, wellness, and self-care. Using the matrix approach described by Miles and Huberman, we organized findings around women's roles, including participants' descriptions of themselves, their health and wellness awareness, self-care practices for health/illness and wellness/nonwellness, barriers to self-care, origin of self-care practices, and perceptions of life control. Implications for health planning and service delivery are presented.

The effect of video-based interventions on self-care

Caregivers for dependent, elderly community dwellers are frequently themselves at risk for illnesses exacerbated by stress. This study evaluates a videotape scenario intervention designed to increase self-care behaviors in three groups of caregivers randomly assigned to a control or to one of two experimental groups. Within the 6- to 8-week trial, attitudes toward self-care became more positive in the experimental groups, and all groups reported endorsement of behavioral changes related to self-care.

Postponing sexual intercourse among urban junior high school students-a randomized controlled evaluation

PURPOSE

To describe a randomized, controlled evaluation of a school-based intervention to delay sexual intercourse among urban junior high school students.

METHODS

Six Washington, D.C., junior high schools were randomly assigned to the intervention or nonintervention control condition for an educational program. During the first school year, seventh graders (n = 582) from the six schools obtained written parental consent to participate. Three health professionals (one per intervention school) implemented the program, which consisted of reproductive health classes, the Postponing Sexual Involvement Curriculum, health risk screening, and "booster" educational activities during the following (eighth grade) school year. Cross-sectional surveys were administered at baseline, the end of the seventh grade, and the beginning and end of the eighth grade. Intervention and control group differences in virginity, attitudes toward delayed sex and childbearing, and sexual knowledge and behavior were assessed at all four time points.

RESULTS

At baseline, 44% of the seventh grade males and 81% of the seventh grade females reported being virgins. At the end of the seventh grade (first follow-up), after controlling for baseline study group differences, intervention-group females were more likely to report virginity, self-efficacy to refuse sex with a boyfriend, and the intention to avoid sexual involvement during the following 6 months. At the end of the eighth grade, significantly more intervention- than control-group females reported virginity, birth control use at last intercourse (for nonvirgins), and knowledge of adolescent reproductive health and confidentiality rights. No changes in virginity, self-efficacy to refuse sex, or sexual intent for the next 6 months were observed among male participants at any time during the study. However, on all three follow-up surveys, intervention-group males scored significantly higher than their control-group counterparts in knowledge of birth control method efficacy. No change in attitudes toward abstinence was observed for either gender at any follow-up point.

CONCLUSIONS

Gender differences in baseline sexual activity rates and in various study outcomes suggest a possible need for separate, gender-specific intervention activities that can adequately address the social and cognitive needs of both sexes.

Parenteral vs oral antibiotics in the prevention of serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia: a meta-analysis

OBJECTIVE

To determine whether parenteral antibiotics are superior to oral antibiotics in preventing serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia.

METHODS

Using the MEDLINE database, the English language literature was searched for all publications concerning bacteremia, fever, or Streptococcus pneumoniae from 1966 to January 1, 1997. All nonduplicative studies with a series of children with S. pneumoniae occult bacteremia having both orally treated and parenterally treated groups were reviewed. Children were excluded from individual studies if at the time of their initial evaluation they were immunocompromised, had a serious bacterial infection, underwent a lumbar puncture, or did not receive antibiotics.

RESULTS

Only 4 studies met study criteria. From these studies, 511 total cases of S. pneumoniae occult bacteremia were identified. Ten of 290 (3.4%) in the oral group and 5 of 221 (2.3%) in the parenteral antibiotic group developed serious bacterial infections (pooled p-value = 0.467, pooled OR = 1.48; 95% CI, 0.5-4.3). Two patients in the oral group (0.7%) and 2 patients in the parenteral group (0.9%) developed meningitis (pooled p-value = 0.699, pooled OR = 0.67; 95% CI, 0.1-5.1).

CONCLUSION

The rates of serious bacterial infections and meningitis did not differ between children who were treated with oral and parenteral antibiotics. The extremely low rate of complications observed in both groups suggests no clinically significant difference between therapies. A study with >7,500 bacteremic children (or >300,000 febrile children) would be needed to have 80% power to prove parenteral antibiotics are superior to oral antibiotics in preventing serious bacterial infections.

Automatic tumor segmentation using knowledge-based techniques

A system that automatically segments and labels glioblastoma-multiforme tumors in magnetic resonance images (MRI's) of the human brain is presented. The MRI's consist of T1-weighted, proton density, and T2-weighted feature images and are processed by a system which integrates knowledge-based (KB) techniques with multispectral analysis. Initial segmentation is performed by an unsupervised clustering algorithm. The segmented image, along with cluster centers for each class are provided to a rule-based expert system which extracts the intracranial region. Multispectral histogram analysis separates suspected tumor from the rest of the intracranial region, with region analysis used in performing the final tumor labeling. This system has been trained on three volume data sets and tested on thirteen unseen volume data sets acquired from a single MRI system. The KB tumor segmentation was compared with supervised, radiologist-labeled "ground truth" tumor volumes and supervised k-nearest neighbors tumor segmentations. The results of this system generally correspond well to ground truth, both on a per slice basis and more importantly in tracking total tumor volume during treatment over time.

A causal functional explanation of maintaining a dependent elder in the community

A causal functional structure demonstrates how a perpetual process, like caregiving, maintains itself. The caregiver functional learning model was used to identify factors influencing caregivers when maintaining dependent elders in the community. These factors include seriousness of illness, power, burden, care quality, self-assurance, an understanding of the elder's needs, and time spent in caregiving. This five-stage theoretical model was tested using a sample of 70 caregivers. Findings supported two of the theoretical relationships: seriousness of illness (beta = .60) with burden (R2 = 0.35), and self-assurance (beta = .36) with time (R2 = 0.18). Three new relationships were added with the empirical model: power (beta = .48) with burden (R2 = 0.52), seriousness of illness (beta = .36) with self-assurance (R2 = 0.11), and burden (beta = .33) with time (R2 = 0.24). A causal functional structure can be used to explain how the phenomenon of caregiving maintains itself.

Perfluorocarbons: future clinical possibilities

Perfluorocarbons are now being used as oxygen carriers in clinical settings. Because these chemicals may have a role as a blood substitute, in organ preservation, and in the management of respiratory failure, we have reviewed some of the research leading to these applications.

Medical image analysis with fuzzy models

This paper updates several recent surveys on the use of fuzzy models for segmentation and edge detection in medical image data. Our survey is divided into methods based on supervised and unsupervised learning (that is, on whether there are or are not labelled data available for supervising the computations), and is organized first and foremost by groups (that we know of!) that are active in this area. Our review is aimed more towards 'who is doing it' rather than 'how good it is'. This is partially dictated by the fact that direct comparisons of supervised and unsupervised methods is somewhat akin to comparing apples and oranges. There is a further subdivision into methods for two- and three-dimensional data and/or problems. We do not cover methods based on neural-like networks or fuzzy reasoning systems. These topics are covered in a recently published companion survey by keller et al.

Long-term follow-up of post-acute traumatic brain injury rehabilitation: a statistical analysis to test for stability and predictability of outcome

A high percentage of the estimated 500,000 traumatic brain injuries (TBI) in the US every year occur with young people who will face many years of neurobehavioral and economic consequences. This study examined the long-term stability of outcome after post-acute TBI rehabilitation and possible predictors of long-term outcome based on a 127-item survey of 332 clients up to 14 years post-discharge. Correlational, factor, and multiple regression analysis indicated positive long-term outcome stability following rehabilitation with the exception of vocational status, which decreased over the same time period. A number of possible explanations for this occupational anomaly are suggested. Rating scale scores and latency-to-rehabilitation proved to be better predictors of long-term outcome than demographic data.

Do oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia? A meta-analysis

OBJECTIVE

To determine whether oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia.

DATA SOURCES

Using the Medline database, the English-language literature was searched for all publications concerning bacteremia, fever, or S pneumoniae from 1966 to April 1996.

STUDY SELECTION

All studies that included a series of children with S pneumoniae occult bacteremia containing orally treated and untreated groups. Children were excluded from individual studies if they were immunocompromised, had a serious bacterial infection, underwent a lumbar puncture, or received parenteral antibiotics.

DATA EXTRACTION

Three authors independently reviewed each article to determine the number of eligible children and the outcome of children meeting entry criteria.

DATA SYNTHESIS

Eleven of 21 studies were excluded, leaving 10 evaluable studies with 656 total cases of S pneumoniae occult bacteremia identified. Patients who received oral antibiotics had fewer serious bacterial infections than untreated patients (3.3% vs 9.7%; pooled odds ratio, 0.35; 95% confidence interval, 0.17 to 0.73). Meningitis developed in 3 (0.8%) of 399 children in the oral antibiotic group and 7 (2.7%) of 257 untreated children (pooled odds ratio, 0.51; 95% confidence interval, 0.12 to 2.09).

CONCLUSION

Although oral antibiotics modestly decreased the risk of serious bacterial infections in children with S pneumoniae occult bacteremia, there was insufficient evidence to conclude that oral antibiotics prevent meningitis. Published recommendations that oral antibiotics be administered to prevent serious bacterial infections in children with possible S pneumoniae occult bacteremia should be reevaluated in light of the lower risk of sequelae from S pneumoniae occult bacteremia and newer data concerning side effects from treatment.

The caregiving story: how the narrative approach informs caregiving burden

The burdens of giving care to a chronically ill or dependent family member can be overwhelming. The therapeutic utilization of narrative can assist elderly female caregivers to transform their feelings of depression and burden into a healthy acceptance of the required care and disabilities of the elder for whom they care. This technique, which assists clients to restory negative aspects of their perceived reality, has emerged from the theoretical framework of postmodernism. Using the narrative approach to a family case study involving a daughter and dependent mother, this article examines interventions that can facilitate the positive development of a client's caregiving story.

Activation of cytokine production and adhesion molecule expression on THP-1 myelomonocytic cells by macrophage colony-stimulating factor in combination with interferon-gamma

THP-1 myelomonocytic leukemia cells cultured with either macrophage colony-stimulating factor (M-CSF) or interferon-gamma (IFN-gamma) alone produce, at best, only low levels of interleukin-1 beta (IL-1 beta) and tumor necrosis factor alpha (TNF-alpha). However, combinations of the two factors resulted in at least 3- to 20-fold greater amounts of IL-1 beta and TNF-alpha than would have been predicted by additive mechanisms. This enhanced cytokine production was observed when M-CSF and IFN-gamma were added simultaneously or when M-CSF was added 24 h after addition of IFN-gamma to the cells. Similar results were obtained with fresh human peripheral blood cells treated with IFN-gamma + M-CSF. Cycloheximide treatment of the cultures containing M-CSF and IFN-gamma inhibited the production of IL-1 beta and TNF-alpha. Northern blotting studies revealed no effect of IFN-gamma alone on IL-1 beta or TNF-alpha mRNA production. IL-1 beta and TNF-alpha mRNA expression was observed at 2 and 6 h after treatment with M-CSF or IFN-gamma + M-CSF. Higher TNF-alpha mRNA expression was observed at 2 and 6 h after treatment with IFN-gamma + M-CSF, and higher IL-1 beta mRNA expression was observed at 2 h after treatment with IFN-gamma + M-CSF compared with mRNA levels observed for cells cultured only with M-CSF. These results suggest that the augmented cytokine production resulting from treatments with combinations of M-CSF and IFN-gamma occurs due to increased cytokine mRNA and increased cytokine protein synthesis. In addition to up-regulating cytokines, combinations of IFN-gamma and M-CSF resulted in augmented cell surface expression of intercellular adhesion molecule-1 and vascular cell adhesion molecule-1. This was accompanied by morphological and functional changes that included plastic adherence, extensive homotypic aggregation, and a macrophage-like appearance. These phenotypic changes and enhancements in cytokine expression and cell surface molecule expression may be related to activation of monocytic cells to become cytotoxic effectors by M-CSF and IFN-gamma combinations. In vitro cytotoxicity against A-375 melanoma cells was greatest for cultures that contained M-CSF and IFN-gamma in combination.

Enhancing critical-thinking skills: faculty-student partnerships in community health nursing

The enhancement of critical-thinking skills empowers students to participate in the building of healthy environments in a variety of settings. The authors describe the development and implementation of unique classroom strategies emphasizing the use of critical thinking by students, the forging of faculty-student partnerships in community health nursing, and the potential impact of these strategies on the expanding horizons of practice.

Rehabilitation technology assessment practices in vocational rehabilitation agencies

A rehabilitation technology assessment is an essential element in the array of rehabilitation technology services provided for vocational rehabilitation (VR) clients. As a part of a comprehensive survey of rehabilitation technology services in VR agencies, information was collected on current practices in rehabilitation technology assessment. Some variation in length, components included, and professionals involved were found among agencies. A complete description of these assessments as reported by VR agencies is discussed and commonalities in current practice are described.

Levamisole causes differential cytokine expression by elicited mouse peritoneal macrophages

Thioglycolate-elicited peritoneal macrophages from normal C57B1/6J mice were examined in vitro for bacterial lipopolysaccharide (LPS)-stimulated interleukin-1 (IL-1), IL-6, and tumor necrosis factor (TNF) production. Macrophages from mice administered a single oral dose of levamisole (3 mg/kg) 1 to 4 days prior to macrophage harvest demonstrated a twofold enhancement of IL-1 production compared to vehicle-treated mice. In contrast, IL-6 production and TNF production by the same macrophages were inhibited up to 36 and 62%, respectively, compared to production by macrophages harvested from vehicle-treated mice. Similar results were observed when IL-1 production and TNF production were followed in peritoneal exidate cells directly stimulated with levamisole in vitro. The ex vivo LPS-stimulated IL-1 production was enhanced 4 days after macrophage elicitation, whereas TNF and IL-6 production returned to baseline by 72 h after macrophage recruitment and augmentation. No evidence could be found for the presence of inhibitors of TNF or IL-6. The specificity of the IL-1, IL-6, and TNF bioactivities was demonstrated by neutralization with specific antisera. Immunoprecipitation studies of supernatants from biosynthetically labeled macrophages also revealed augmented IL-1 production and decreased IL-6 and TNF, indicating that levamisole may have affected cytokine production at the translational level. Kinetics studies revealed that ex vivo release of IL-6 and TNF by macrophages from levamisole-dosed mice was delayed compared to production of these cytokines by macrophages harvested from mice given vehicle only. The results may explain, in part, the reported ability of levamisole to ameliorate cases of rheumatoid arthritis or other autoimmune and inflammatory diseases by affecting the relative levels of cytokines produced by macrophages recruited to sites of injury, which are associated with inflammation and acute-phase protein synthesis.

Older adults and daily living task profiles

This paper describes data generated from a comprehensive study in which human factors techniques were applied to the analysis of 25 personal and instrumental activities of daily living (ADLs) performed by 60 older adults (age 55 to 93 years) living in the community. Demand profiles generated from task analysis of video-taped ADLs identify the demands inherent in task activities and the objects and environments associated with them. Examples of four different approaches to examine ADL performance using demand profiles are presented: global descriptions of demands across all ADL tasks, task component profiles, task-specific profiles, and action profiles.

In what ways, if any, are child abusers different from other parents?

In recent years a variety of alternative theoretical models have been developed to aid our understanding and to guide research in this area. This essay considers in particular the psychiatric model and the social interactional model of child abuse, together with research studies comparing physically abusive and non-abusive families. It will be concluded that research has pinpointed several important distinguishing features in the behaviour of abusive versus non-abusive families. A pattern of behaviour with their child is displayed by abusers that is proportionately more aversive than for non-abusers, and observations of parent-child interactions have revealed qualitative differences in patterns of interaction which seem to be a significant factor in the differentiation of abusive from non-abusive families.

Interstitial deletion (6) (q11----q15) in an infant with congenital abnormalities

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Social support, perceived control, and well-being: a study of an environmentally stressed population

Interviews were conducted with elderly residents of an area targeted for massive redevelopment. Social support was considered simultaneously with health and personal control beliefs in relation to well-being, and the unresolved issue of the sufficiency of one support figure was explored. Health, control, and support each emerged as independent predictors of after and life satisfaction, and affect was significantly lower for those with no close support figure than for those with one close relationship. The results suggest that one close support figure may be sufficient to promote well-being, but alternative interpretations are possible.

Characterization of a plasmid in isolates of Corynebacterium sepedonicum

Lysis of mid-log phase cells of the Gram-positive bacterium, Corynebacterium sepedonicum, by a combination of lysozyme treatment and incubation with alkaline sodium dodecyl sulfate at 56 degrees C led to the recovery of a single plasmid. The plasmid was purified in CsCl density gradients, and its molecular weight estimated to be 31 megadaltons (46 kilobases), as determined from its relative mobility in agarose gels, from its contour dimensions in electron micrographs, and from the size of the fragments generated when it was cleaved with various restriction endonucleases. Thirteen widely divergent isolates of C. sepedonicum were screened for the presence of plasmid, and of these, 11 were shown to harbour a single plasmid at a level of about 30 copies per cell. Cleavage of the plasmid with PstI gave an identical banding pattern in agarose gels for the fragments from all of the plasmid-carrying isolates. The relevance of plasmid incidence and distribution in C. sepedonicum is discussed in relation to the possibility of developing a test for the detection of bacterial ring rot by using plasmid DNA as a hybridization probe.

Social support and well-being: preliminary indicators based on two samples of the elderly

The structure of social support and its relation to health, affect, and life satisfaction are compared for two samples of the elderly. The first is a national representative sample; the second is a distressed sample from South Miami Beach. Although there are similarities in the structure of social support across the two groups, those in the Miami Beach sample report fewer support figures, and far fewer within geographic proximity, than do those in the national sample. This comparative network impoverishment is particularly marked for male respondents and is accentuated by a high number of isolates in this group. In addition, stronger relationships are found between support network size and affect, and among affect, life satisfaction, and health in the South Miami Beach sample. Older men in poor health and without supportive relationships are targeted as a particularly high risk subgroup. The discussion includes a focus on personal, situational, and life span differences related to variations in support and well-being and a consideration of implications for more recent waves of elderly sun-belt migrants.

Comparison of the echocardiographic and hemodynamic diagnosis of rheumatic tricuspid stenosis

Two-dimensional echocardiography has proved to be reliable in the diagnosis of mitral, aortic and pulmonary stenosis. Its role in the diagnosis of rheumatic tricuspid stenosis is still being defined; therefore, the tricuspid valve echograms of 147 patients with rheumatic heart disease were examined. Thirty-eight of these patients also underwent hemodynamic evaluation. Tricuspid stenosis was defined echocardiographically as diastolic anterior leaflet doming, thickening and restricted excursion of the other two tricuspid leaflets and decreased separation of the leaflet tips. Using these criteria, the sensitivity and specificity of the echocardiogram in detecting tricuspid stenosis were 69 and 96%, respectively, in the group of 38 patients who had both echocardiographic and hemodynamic evaluations. However, when the smaller group of 17 patients who had simultaneous right atrial and right ventricular pressure recordings were considered separately, there was complete agreement between the echocardiographic and hemodynamic data. Thus, the two-dimensional echocardiogram is a sensitive and specific test for diagnosing rheumatic tricuspid stenosis. In addition, these data provided an opportunity to determine the prevalence of tricuspid stenosis in this group of patients with chronic rheumatic valvular disease. Tricuspid stenosis was present in 14 (9.5%) of the total group of 147 patients who had two-dimensional echocardiograms, and in 10 (26.3%) of the 38 who had both echocardiographic and hemodynamic studies. In patients with rheumatic heart disease about to undergo cardiac catheterization, an echocardiographic study should prove useful in making the diagnosis of tricuspid stenosis.

Permeability pulmonary edema caused by venous air embolism

A 22-yr-old man developed severe pulmonary edema after blowing air into tubing connected to a catheter inserted in a vein in his forearm. Pulmonary edema was rapid in onset, peaking in intensity about 12 h after the air had been insufflated. The patient's edema fluid to plasma protein concentration ratio of 0.79 showed that the edema fluid was rich in protein. Vascular pressures were normal except for mild pulmonary arterial hypertension and systemic hypotension. The patient's clinical course, edema fluid protein concentration, and vascular pressures were characteristic of an increased microvascular permeability type of pulmonary edema. The patient recovered fully within 48 h of the air infusion. His response to venous air embolism was similar to findings in an experimental model of pulmonary edema in sheep infused with venous air emboli. As long as air is not infused continuously for long periods or in very large amounts, this disorder is probably self-limiting, and supportive care may be the only treatment necessary.

Thin-foil fabrication

A method has been developed to produce seamless, freestanding plastic cylinders with dimensions up to 18 cm in diameter, 4 cm in height and with mass density from 15 mug/cm to 300 mug/cm (approximately 0.15 to 3 mu thick). The polyvinyl formal resin may be subsequently coated with a variety of material by vapor deposition. The method employs standard thin-foil fabrication techniques modified for use in cylindrical geometry and results in uniform reproducible cylinders.

Purine metabolism and differential inhibition of spore germination in Phytophthora infestans

An analysis of the effect of various purines and pyrimidines on the germination process in three different isolates of the late blight fungus, Phytophthora infestans, revealed increased rates of indirect germination in one isolate by adenine, hypoxanthine, and the riboside of dimethylaminopurine. This observation coupled with the capacity of sporangia of the race affected (1.2.3.4) for the uptake and interconversion of purines, as demonstrated by experiments with labelled purines under in vivo and in vitro conditions, pointed to hypoxanthine as a key intermediate in the purine metabolism directly associated with spore formation and development. This enhanced germination contrasted sharply with the almost complete arrest of indirect germination that occurred when sporangia were incubated with the purine analogue, benzimidazole, or with either of the respiratory inhibitors, sodium azide and 2,4-dinitrophenol. The pattern of differential inhibition exhibited by sporangia versus zoospores upon treatment with actinomycin D, 4-FLUOROURACIL, OR CYCLOHEXIMIDE INDICATED THat continued translation on preformed messenger RNA may be one essential requirement for the formation and release of zoospores, whereas their subsequent germination and development may depend upon renewed transcription as well.