Pathogen-Specific Humoral Immunity and Infections in B Cell Maturation Antigen-Directed Chimeric Antigen Receptor T Cell Therapy Recipients with Multiple Myeloma.

Chimeric antigen receptor (CAR) T cell therapy targeting B cell maturation antigen (BCMA-CARTx) is an emerging treatment for relapsed or refractory multiple myeloma (R/R MM). Here we characterize the epidemiology of infections, risk factors for infection, and pathogen-specific humoral immunity in patients receiving BCMA-CARTx for R/R MM. We performed a retrospective cohort study in 32 adults with R/R MM enrolled in 2 single-institution phase 1 clinical trials of BCMA-CARTx administered after lymphodepleting chemotherapy alone (n = 22) or with a gamma secretase inhibitor (GSI). We tested serum before and up to approximately 180 days after BCMA-CARTx for measles-specific IgG and for any viral-specific IgG using a systematic viral epitope scanning assay to describe the kinetics of total and pathogen-specific IgG levels pre- and post-BCMA-CARTx. We identified microbiologically documented infections to determine infection incidence and used Poisson regression to explore risk factors for infections within 180 days after BCMA-CARTx. Most individuals developed severe neutropenia, lymphopenia, and hypogammaglobulinemia after BCMA-CARTx. Grade ≥3 cytokine release syndrome (CRS; Lee criteria) occurred in 16% of the participants; 50% of the participants received corticosteroids and/or tocilizumab. Before BCMA-CARTx, 28 of 32 participants (88%) had an IgG <400 mg/dL, and only 5 of 27 (19%) had seropositive measles antibody titers. After BCMA-CARTx, all participants had an IgG <400 mg/dL and declining measles antibody titers; of the 5 individuals with baseline seropositive levels, 2 remained above the seroprotective threshold post-treatment. Participants with IgG MM (n = 13) had significantly fewer antibodies to a panel of viral antigens compared with participants with non-IgG MM (n = 6), both before and after BCMA-CARTx. In the first 180 days after BCMA-CARTx, 17 participants (53%) developed a total of 23 infections, of which 13 (57%) were mild-to-moderate viral infections. Serious infections were more frequent in the first 28 days post-treatment. Infections appeared to be more common in individuals with higher-grade CRS. Individuals with R/R MM have substantial deficits in humoral immunity. These data demonstrate the importance of plasma cells in maintaining long-lived pathogen-specific antibodies and suggest that BCMA-CARTx recipients need ongoing surveillance for late-onset infections. Most infections were mild-moderate severity viral infections. The incidence of early infection appears to be lower than has been reported after CD19-directed CARTx for B cell neoplasms, possibly due to differences in patient and disease characteristics and regimen-related toxicities.

The Influence of Culture on Teamwork and Communication in a Simulation-Based Resuscitation Training at a Community Hospital in Honduras.

STATEMENT: Communication and teamwork are important aspects of medicine and have been a recent focus of resuscitation. Culture can influence communication and teamwork, and these effects have not been studied in low-resource settings. Using a case study and the TEAM scale, we evaluated how culture influences teamwork and communication during resuscitation simulations, in addition to examining other challenges of simulation research in low-resource settings. We observed lower scores in leadership and communication skills than have been seen in other studies using the TEAM scale, which led us to evaluate the possible role of culture in influencing these skills. The high power distance and collectivism in Latin America can make communication difficult, especially during debriefing. Furthermore, in a male-biased medical hierarchy, female nurses may be less likely to voice concerns. Ultimately, this commentary provides advice for taking the influences of culture into account when planning future simulation training in low-resource settings.

Does the number of sentinel lymph nodes removed affect the false negative rate for head and neck melanoma?

BACKGROUND AND OBJECTIVES: Head and neck (HN) cutaneous melanoma is associated with worse disease-free survival compared to non-HN cutaneous melanoma, possibly due to inadequate staging. We aim to determine if a higher yield of sentinel lymph nodes (SLNs) affected rates of sentinel lymph node biopsy (SLNB) positivity. METHODS: Two Cancer Registries were used to identify patients who underwent SLNB for HN melanoma. A false negative (FN) was defined by nodal recurrence after negative SLNB. RESULTS: Out of 333 patients who underwent SLNB, 20% (n = 69) had a positive SLN with a FN rate of 6.3%. Those with three or more SLNs had a higher rate of SLN positivity (23.8% [17.5-29.9% CI] vs 16.4% [10.7-23.6% CI]), a lower FN rate (16.7% [10.2-21.2% CI] vs 35.3% [27.1-42.9% CI]), and higher sensitivity (83.3% [82.59-84.09% CI] vs 65.7% [64.87-66.53% CI]) compared to those with one or two SLNs. Of patients in Group 1 (one or two SLNs) with a positive SLN who underwent completion lymph node dissection (20/23), 47% (33-61% CI) had one or more positive non-sentinel nodes compared to 29% (16-51%) of patients in Group 2 (three or more SLNs) (42/46). CONCLUSION: In HN melanoma cases in which multiple nodes are identified, removal of all SLNs will more adequately stage patients.

Breaking Down the Objective Structured Clinical Examination: An Evaluation of the Helping Babies Breathe OSCEs.

INTRODUCTION: Helping Babies Breathe (HBB) is a simulation-based neonatal resuscitation curriculum designed for low-resource settings. At the completion of the workshop, learners complete the following four assessments: a multiple-choice question (MCQ) test, bag-mask ventilation (BMV) checklist, and two objective structured clinical examinations (OSCEs). Objective structured clinical examinations are clinical performance assessments that evaluate learners' skills in simulated scenarios. The aims of this study were (1) to evaluate the validity and reliability of the OSCEs used in the HBB curriculum, (2) to conduct an itemized analysis of the OSCEs to identify specific deficits in knowledge and performance, and to identify areas of improvement for future versions of HBB. METHODS: Seventy physicians and nurses completed an HBB workshop conducted in Spanish at a Honduran community hospital. Validity and reliability were examined using an item analysis of item difficulty, discrimination, correlation, and internal consistency/reliability. RESULTS: Posttest scores were higher for all assessments. Most items on the OSCEs were of low difficulty and low discrimination. Item agreement was lowest for multistep items. CONCLUSIONS: As summative and formative assessments of performance in simulated neonatal resuscitation, the HBB OSCEs are effective because most learners were able to perform the skills correctly after an HBB workshop. On the basis of our results, we recommend changes to future editions of HBB, including the following: simplification of multistep items to single tasks, use of a global rating scale, provision of additional scenarios, and specific instructions to raters on how to grade OSCEs and promote self-reflection to enhance debriefings/feedback. Further validation and study of the OSCEs in the second edition of HBB would enhance their quality and translation into clinical performance.

High Glucose-Mediated STAT3 Activation in Endometrial Cancer Is Inhibited by Metformin: Therapeutic Implications for Endometrial Cancer.

OBJECTIVES: STAT3 is over-expressed in endometrial cancer, and diabetes is a risk factor for the development of type 1 endometrial cancer. We therefore investigated whether glucose concentrations influence STAT3 expression in type 1 endometrial cancer, and whether such STAT3 expression might be inhibited by metformin. METHODS: In Ishikawa (grade 1) endometrial cancer cells subjected to media with low, normal, or high concentrations of glucose, expression of STAT3 and its target proteins was evaluated by real-time quantitative PCR (qPCR). Ishikawa cells were treated with metformin and assessed with cell proliferation, survival, migration, and ubiquitin assays, as well as Western blot and qPCR. Expression of apoptosis proteins was evaluated with Western blot in Ishikawa cells transfected with a STAT3 overexpression plasmid and treated with metformin. A xenograft tumor model was used for studying the in vivo efficacy of metformin. RESULTS: Expression of STAT3 and its target proteins was increased in Ishikawa cells cultured in high glucose media. In vitro, metformin inhibited cell proliferation, survival and migration but induced apoptosis. Metformin reduced expression levels of pSTAT3 ser727, total STAT3, and its associated cell survival and anti-apoptotic proteins. Additionally, metformin treatment was associated with increased degradation of pSTAT3 ser727. No change in apoptotic protein expression was noticed with STAT3 overexpression in Ishikawa cells. In vivo, metformin treatment led to a decrease in tumor weight as well as reductions of STAT3, pSTAT3 ser727, its target proteins. CONCLUSIONS: These results suggest that STAT3 expression in type 1 endometrial cancer is stimulated by a high glucose environment and inhibited by metformin.

Educational outcomes of Helping Babies Breathe training at a community hospital in Honduras.

OBJECTIVES: Helping Babies Breathe is an evidence-based curriculum designed to teach basic neonatal resuscitation in low-resource countries. The purpose of this study was to evaluate the acquisition of knowledge and skills following this training and correlation of learner characteristics to performance in a Spanish-speaking setting. METHODS: Thirty-one physicians and 39 nurses completed Helping Babies Breathe training at a Honduran community hospital. Trainee knowledge and skills were evaluated before and after the training using a multiple-choice questionnaire, bag-mask ventilation skills test, and two objective structured clinical exams (OSCEs). Linear mixed-effects models were used to analyze assessment scores pre- and post-training by profession (physician or nurse) while controlling for covariates. RESULTS: Helping Babies Breathe training resulted in significant increases in mean scores for the multiple-choice question test, bag-mask ventilation skills test, and OSCE B. Time to initiation of effective bag-mask ventilation decreased from a mean of 74.8 to 68.4 s. Despite this improvement in bag-mask ventilation, only 42 % of participants were able to initiate effective bag-mask ventilation within the Golden Minute. Although physicians scored higher on the pre-test multiple-choice questions and bag-mask ventilation, nurses demonstrated a greater mean difference in scores after training. OSCE B scores pre- and post-training increased similarly between professions. Nurses' and physicians' performance in simulation was not significantly different after the training. Assessment scores and course feedback indicated a need for more skills practice, particularly with bag-mask ventilation. CONCLUSIONS: When evaluated immediately after an initial workshop, Helping Babies Breathe training resulted in significant gains in neonatal resuscitation knowledge and skills. Following training, nurses, who commonly do not perform these skills in real-life situations, were able to perform at a similar level to physicians. Further studies are necessary to determine how to sustain this knowledge and skills over time, tailor the course to learner characteristics, and whether this training translates into improvements in clinical practice.

Obstetric referrals from a rural clinic to a community hospital in Honduras.

OBJECTIVES: referrals between health care facilities are important in low-resource settings, particularly in maternal and child health, to transfer pregnant patients to the appropriate level of obstetric care. Our aim was to characterise the obstetrical referrals from a rural clinic to a community referral hospital in Honduras, to identify barriers in effective transport/referral, and to describe subsequent patient outcomes. METHODS: we performed a descriptive retrospective study of patients referred during a 9-month period. We reviewed patient charts to review diagnosis, referral, and treatment times at both sites to understand the continuity of care. RESULTS: ninety-two pregnant patients were referred from the rural clinic to the community hospital. Twenty six pregnant patients (28%) did not have complete and accurate medical records and were excluded from the study. The remaining 66 patients were our study population. Of the 66 patients, 54 (82%) received antenatal care with an average of 5.5±2.4 visits. The most common diagnoses requiring referral were non-reassuring fetal status, hypertensive disorders of pregnancy, and preterm labour. The time spent in the rural clinic until transfer was 7.35±8.60 hours, and transport times were 4.42±1.07 hours. Of the 66 women transferred, 24 (36%) had different primary diagnoses and 16 (24%) had additional diagnoses after evaluation in the community hospital, whereas the remaining 26 (40%) had diagnoses that remained the same. No system was in place to give feedback to the referring clinic doctors regarding their primary diagnoses. CONCLUSIONS: our results demonstrate challenges seen in obstetric transport from a rural clinic to a community hospital in Honduras. Further research is needed for reform of emergency obstetric care management, targeting both healthcare personnel and medical referral infrastructure. The example of Honduras can be taken to motivate change in other resource-limited areas.

Overexpression of miR-155 causes expansion, arrest in terminal differentiation and functional activation of mouse natural killer cells.

It is known that microRNAs (miRs) are involved in lymphocyte development, homeostasis, activation, and occasionally malignant transformation. In this study, a miR-155 transgene (tg) was driven to be overexpressed off of the lck promoter in order to assess its effects on natural killer (NK) cell biology in vivo. miR-155 tg mice have an increase in NK-cell number with an excess of the CD11b(low)CD27(high) NK subset, indicative of a halt in terminal NK-cell differentiation that proved to be intrinsic to the cell itself. The increase in NK cells results, in part, from improved survival in medium alone and enhanced expansion with endogenous or exogenous interleukin 15. Phenotypic and functional data from miR-155 tg NK cells showed constitutive activation and enhanced target cell conjugation, resulting in more potent antitumor activity in vitro and improved survival of lymphoma-bearing mice in vivo when compared with wild type NK cells. The enhanced NK-cell survival, expansion, activation, and tumor control that result from overexpression of miR-155 in NK cells could be explained, in part, via diminished expression of the inositol phosphatase SHIP1 and increased activation of ERK and AKT kinases. Thus, the regulation of miR-155 is important for NK-cell development, homeostasis, and activation.

miR-155 regulates IFN-γ production in natural killer cells.

MicroRNAs (miRs) are small, noncoding RNA molecules with important regulatory functions whose role in regulating natural killer (NK) cell biology is not well defined. Here, we show that miR-155 is synergistically induced in primary human NK cells after costimulation with IL-12 and IL-18, or with IL-12 and CD16 clustering. Over-expression of miR-155 enhanced induction of IFN-γ by IL-12 and IL-18 or CD16 stimulation, whereas knockdown of miR-155 or its disruption suppressed IFN-γ induction in monokine and/or CD16-stimulated NK cells. These effects on the regulation of NK cell IFN-γ expression were found to be mediated at least in part via miR-155's direct effects on the inositol phosphatase SHIP1. Consistent with this, we observed that modulation of miR-155 overrides IL-12 and IL-18-mediated regulation of SHIP1 expression in NK cells. Collectively, our data indicate that miR-155 expression is regulated by stimuli that strongly induce IFN-γ in NK cells such as IL-12, IL-18, and CD16 activation, and that miR-155 functions as a positive regulator of IFN-γ production in human NK cells, at least in part via down-regulating SHIP1. These findings may have clinical relevance for targeting miR-155 in neoplastic disease.