Early lymphocyte collection for anti-CD19 CART production improves T-cell fitness in patients with relapsed/refractory diffuse large B-cell lymphoma.

BACKGROUND: Chimeric antigen receptor (CAR) T cells targeted to the CD19 B-cell antigen form an approved treatment for patients with relapsed/refractory diffuse large B-cell lymphoma (r/r DLBCL). However, since this therapy is administered after multiple lines of treatment and exposure to lymphotoxic agents, there is an urgent need to optimize this modality of treatment. METHODS: To circumvent the difficulties of harvesting adequate and optimal T cells from DLBCL patients and improve CART therapy, we suggest an earlier lymphopheresis (i.e. at first relapse, before salvage treatment). We conducted a prospective study and evaluated the potential benefit of an earlier lymphopheresis (early group, n = 22) on the clinical outcome of CD19-CART infused DLBCL patients, in comparison with standard lymphopheresis (i.e. at second relapse and beyond; standard group, n = 23). RESULTS: An increased percentage of naïve T cells and increased in vitro T-cell functionality were observed in the early group. Additionally, these cells exhibit a lower exhaustion profile than T cells collected in the standard group. CONCLUSION: While improved T-cell phenotype and function in the lymphopheresis product did not translate into significantly improved clinical outcomes, a trend towards better overall survival (OS) and progression-free survival (PFS) was observed. Early lymphopheresis maximizes the potential of salvage therapies, without compromising CAR T-cell quality.

Justifying CT prior to MRI in cases of suspected occult hip fracture. A proposed diagnostic protocol.

INTRODUCTION: Patients with clinical suspicion of hip fracture, but negative radiographs are suspected of having an occult hip fracture (OHF). Different diagnostic modalities are available for investigating OHF and various protocols have been suggested. MRI has the highest sensitivity and specificity, however availability is limited in many institutes. CT is readily accessible in the large majority of hospitals throughout the world but has lower sensitivity and may miss some fractures. In this article we investigate a protocol that balances these issues providing a practical and cost-effective solution. METHODS: During a four-year period between 2012 and 2016 a strict diagnostic protocol was followed at our Medical Center for patients suspected of OHF. This MRI selective protocol consisted of CT initially being performed and only when negative for fracture, followed by an MRI. Retrospective analysis of all patients who followed the protocol was performed. The patients were divided into two groups: those diagnosed by CT alone and those diagnosed by MRI after having a negative CT scan. Diagnostic performance, time to diagnosis and the cost of this protocol were evaluated. RESULTS: 103 patients were treated under the protocol. In 50 patients (49%) hip fracture was diagnosed by CT alone. In the remaining 53 patients (51%) no definitive diagnosis was reached by CT and MRI was subsequently performed. 12 of these 53 patients (23%) were diagnosed with hip fracture necessitating surgery. In the CT only group mean time from admission to diagnosis was 3 hours, in the CT + MRI group this rose to 40 hours. Cost analysis showed that this protocol was more cost-effective than performing MRI in all patients, saving an estimated 66,805 Euro during the study period. CONCLUSION: The clinical challenge of diagnosing OHF can be minimised by implementing a diagnostic protocol. The protocol should take into consideration the diagnostic sensitivity, availability and cost of different imaging modalities. An MRI selective strategy with initial CT scanning is recommended, as it reduces time to diagnosis and lowers overall costs.

Reproducibility of geometric and flow-based echocardiographic measurements used for quantification of left ventricular total and forward stroke volume in healthy dogs.

BACKGROUND: Cardiac structure and function in dogs are commonly assessed using echocardiography. A variety of linear, area, and flow-based measurements can be used to calculate left ventricular (LV) total stroke volume (TSV) and forward stroke volume (FSV), but the reproducibility of many of these measurements has not been fully studied. We hypothesized that survey of echocardiographic variables would identify those with high reproducibility and inform future investigation of different methods to measure LV TSV and FSV. METHODS: The reproducibility of 25 geometric and flow-based echocardiographic measurements was prospectively evaluated in 23 healthy dogs by two experienced observers. Reproducibility (i.e., interobserver agreement) was described using intraclass correlation coefficients. The reproducibility of various methods to calculate LV TSV and FSV was explored. RESULTS: Reproducibility was generally good to excellent. Variables of LV width, length, and area and aortic and sinotubular junction diameter and velocity time integral were among measures with the highest reproducibility. Measurements of mitral annular diameter and mitral inflow velocity time integral possessed lower reproducibility. Calculation of LV TSV using measurements involved in the cube and bullet formulas demonstrated higher reproducibility than the Simpson's method of disks or mitral inflow methods. Calculation of LV FSV using LV outflow tract and aortic diameters from the right parasternal view generally demonstrated higher reproducibility compared with the left-sided view. CONCLUSIONS: The reproducibility of many simple geometric and flow-based echocardiographic measurements is high. Comparison of the reliability of different measurement informs future investigation of echocardiographic methods to determine LV TSV and FSV in dogs.

Skeletal injuries sustained during the Haiti earthquake of 2010: a radiographic analysis of the casualties admitted to the Israel Defense Forces field hospital.

PURPOSE: To report the distribution and types of skeletal injuries demonstrated on the images taken at the field hospital following the Haiti 2010 earthquake. METHODS: Following the January 12, 2010, earthquake, the State of Israel dispatched a field hospital to Haiti, managing 1,111 patients from January 17, 2010, to January 26, 2010. Four hundred and seven patients (37 %) had 684 radiographic images, most of them (87 %) due to presumed skeletal injuries. RESULTS: There were 224 limb fractures (excluding the hands and feet), with 77 % of them in the lower limbs (30 % femur, 17 % tibial shaft, 16 % ankle). Out of 37 axial skeleton fractures, 30 involved the pelvis (21 anterior posterior, three vertical shear, three lateral compression, three combined). Nine traumatic dislocations (five hips, three shoulders, one knee) were reduced. After reviewing all the digital radiographs, on a PACS-compatible radiography screen, few false diagnoses (2 %) were encountered, with none of them affecting the management of these injuries. CONCLUSIONS: To the best of our knowledge, this is the first report of the radiological results emerging from a field hospital following a mass casualty event. Laptop personal computer-based workstations provide an adequate solution for radiographic image viewing in a field hospital setting. Recognition of the prevalence and distribution of skeletal injuries can improve the preparedness of such delegations before departure in the future.

[Treatment of pediatric femur fractures by immediate reduction and spica cast application--clinical and economical feasibility in the Israeli medical system].

BACKGROUND: Pediatric femur fractures are common injuries necessitating immediate application of spica cast or surgical stabilization. Currently, neither conservative nor operative fixation shows superior results; nevertheless, operative intervention has become more common lately. The current study retrospectively investigates short term results of immediate spica cast application, as well as the economic consequences of this treatment. METHODS: All cases of pediatric (6 months - 6 years) femur fractures treated in a single medium-sized hospital during 3 years were reviewed. Characteristics of fracture treatment and economical aspects were analyzed. RESULTS: Twenty four patients (17 boys and 7 girls, mean age 2.5 years, range 9 months to 5.5 years), were treated during the study period by immediate closed reduction and spica cast application. Eleven patients were also treated for medical reasons. All cases achieved acceptable alignment and shortening after cast removal. Two patients were re-admitted to the hospital Emergency Room but no changes in treatment were needed, one patient needed re-reduction. Mean hospital stay was 2.75 days. Calculated cost of such treatment is estimated to be almost equal to the compensation given by insurance companies (based on hospital stay in Israel). CONCLUSIONS: Immediate application of spica cast for pediatric femur fractures, achieves its goals of appropriate fracture-alignment and acceptable complication rates. The authors believe that the compensation should be procedure-based and not hospital-stay based, in a way that will encourage higher efficacy of medical treatment and shortened hospital stay.

Colorectal cancer in the south of Israel; comparison of the clinical characteristics and survival between two periods, 1981-2 and 1986-7.

BACKGROUND: Colorectal cancer has the highest incidence of all malignant tumours in men and women in Israel. The public was introduced to the concept of screening in the early 1980s, and full programs began in 1983. OBJECTIVES: The study compares patients with colorectal cancer (CRC) who were diagnosed before screening and five years later, for stage differences and survival. METHODS: All patients with CRC who were diagnosed from 1981 to 1982 (period I) and 1986-87 (period II) at Soroka Medical Centre and who were residents of the Negev area were eligible for the study. Data were collected retrospectively from the Israel Cancer Registry and patient files and endoscopic, histological and surgical reports from the Departments of Pathology, Gastroenterology, Oncology and Surgery at Soroka Medical Centre. RESULTS: The study groups included 207 patients with CRC, 85-from period I and 122-from period II. The mean annual incidence of CRC for these 2 periods was 18 and 24.8 cases per 100, 000, respectively, for an increase of 37% (P < 0.001). Five-year-survival in period I was 53.3% and in period II, 39.6% (P = 0.025). Survival did not differ by origin or gender. Dukes' stage, well and moderately differentiated tumours, and left-sided tumours were associated with better prognosis (P = 0.03). Forty-two percent of the cases were less than 64-year-old-at diagnosis, compared with 27% of 2069 Israeli patients in whom CRC was diagnosed in 1991 (P < 0.001). CONCLUSIONS: Before a nation wide decision is made with regard to public screening for CRC with fecal occult blood tests or sigmoidoscopy, the available data should be thoroughly evaluated, and further in-depth investigations performed to determine trends in diagnosis and prognosis.

Outcome of total hip arthroplasty in patients with Gaucher disease.

This retrospective survey includes 29 total hip arthroplasties (THAs) in 23 patients with Gaucher disease, with heterogeneous techniques, with various prostheses, and performed by 9 different surgical teams. THA was discouraged in patients with Gaucher disease because of a tendency toward infection, poor bone matrix because of Gaucher cell infiltration, and deterioration of matrix with disease progression. Subjective assessment of pain and function, objective examination of outcome, and radiologic signs of loosening after THA were evaluated. In primary THAs, there was enhancement of quality of life, allowing restoration of full participation in normal activities; function was improved; radiologic evidence of loosening was low; and there were no infections. In revisions, the results were not as good. THA is recommended in this population using criteria comparable to those in other patients, with equally good results.

Selective involvement of interleukin-6 in the transcriptional activation of the suppressor of cytokine signaling-3 in the brain during systemic immune challenges.

Cytokine-inducible proteins named as suppressors of cytokine signaling (SOCS) are rapidly induced by interleukin-6 (IL-6) and other members sharing the gp130 receptor subunit after activation of the Janus kinases (JAK) and the signal transducers and activators of transcription (STAT). These inhibitory proteins generally prevent tyrosine phosphorylation of IL-6 receptor signaling subunit gp130, specific JAK and STAT or in acting at steps distal to JAK activation. Expression of these inhibitory proteins is therefore a useful tool to investigate the signaling events occurring in the brain during immunogenic stimuli that involve cytokines of the IL-6 family. This study investigated the effect of ip lipopolysaccharide (LPS) administration on the expression of one key member of the SOCS family, SOCS-3, in both rats and mice. In rats, the endotoxin caused a profound transcriptional activation of the inhibitory factor in the circumventricular organs subfornical organ, organum vasculosum of the lamina terminalis, arcuate nucleus/median eminence, area postrema, choroid plexus, leptomeninges, ependymal lining cells, and along the endothelium of the brain blood vessels. The hybridization signal for SOCS-3 messenger RNA was low at 1 h, but robust at 3 and 6 h and declined to return to basal levels 12 h after the single ip LPS injection. The pattern of SOCS-3 expression was similar in the brain of wild-type mice, although induction of the inhibitory factor was no longer observed in the ependymal lining cells of the cerebral ventricles and the blood microvessels of IL-6-deficient animals at all the times evaluated, i.e. from 1-8 h post-LPS injection. The endothelium of the brain capillaries also exhibited up-regulation of both IL-6 receptor and gp130 subunits during systemic inflammation, which allowed SOCS-3 expression in response to circulating IL-6. The present data indicate that the JAK/STAT transduction pathways that lead to SOCS-3 transcription are activated within cells accessible from the blood circulation, but not within deep parenchymal elements of the brain during endotoxemia. Induction of SOCS-3 followed the cascade of events that take place during the acute phase response and the contribution of IL-6 in activating the inhibitory factor is site specific and not generalized throughout the central nervous system.

[Syme amputation of the foot--is it appropriate for foot infections in diabetics?].

Syme ankle disarticulation for foot infections in diabetics with concomitant peripheral vascular disease is often unsuccessful. The need for re-amputation usually results from recurrent infection or ischemia of the posterior heel flap. We present 5 such cases of deep foot infections in diabetics who underwent Syme amputation after failure of local debridement. All patients needed reamputation in 4-18 days for ischemia of the flap.

[Lymphoma of the knee joint simulating patellar fracture].

Fracture of the patella is not uncommon after direct anterior knee trauma. However, there are other medical situations that resemble it radiologically. We present a patient mistakenly diagnosed as having a patellar fracture who had primary, solitary, malignant B-cell lymphoma of the knee space eroding the lower pole of the patella. We have found no reports of such a lesion in the literature. Another common benign condition that might erode adjacent bone is chronic synovitis. Our patient was treated with chemo- and radiotherapy and the lesion fully regressed with no evidence of local or systemic recurrence 1.5 years after diagnosis.

Functional analysis of regulatory sequences controlling PR-1 gene expression in Arabidopsis.

The Arabidopsis PR-1 gene is one of a suite of genes induced co-ordinately during the onset of systemic acquired resistance (SAR), a plant defense pathway triggered by pathogen infection or exogenous application of chemicals such as salicylic acid (SA) and 2,6-dichloroisonicotinic acid (INA). We have characterized cis-acting regulatory elements in the PR-1 promoter involved in INA induction using deletion analysis, linker-scanning mutagenesis, and in vivo footprinting. Compared to promoter fragments of 815 bp or longer (which show greater than 10-fold inducibility after INA treatment), induction of a 698 bp long promoter fragment is reduced by half and promoter fragments of 621 bp or shorter have lost all inducibility. Additionally, two 10-bp linker-scanning mutations centered at 640 bp and 610 bp upstream from the transcription initiation site are each sufficient to abolish chemical inducibility of a GUS reporter fusion. The -640 linker-scanning mutation encompasses a region highly homologous to recognition sites for transcription factors of the basic leucine zipper class, while the -610 linker-scanning mutation contains a sequence similar to a consensus recognition site for the transcription factor NF-kappa B. Furthermore, several inducible in vivo footprints located at or nearby these motifs demonstrate significant and highly reproducible changes in DNA accessibility following SAR induction. This in vivo signature of protein-DNA interactions after INA induction is tightly correlated with the functionally important regions of the promoter identified by mutation analysis.

Differential impact of miniature synaptic potentials on the soma and dendrites of pyramidal neurons in vivo.

We studied the impact of transmitter release resistant to tetrodotoxin (TTX) in morphologically identified neocortical pyramidal neurons recorded intracellularly in barbiturate-anesthetized cats. It was observed that TTX-resistant release occurs in pyramidal neurons in vivo and at much higher frequencies than was previously reported in vitro. Further, in agreement with previous findings indicating that GABAergic and glutamatergic synapses are differentially distributed in the somata and dendrites of pyramidal cells, we found that most miniature synaptic potentials were sensitive to gamma-aminobutyric acid-A (GABA(A)) or alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) antagonists in presumed somatic and dendritic impalements, respectively. Pharmacological blockage of spontaneous synaptic events produced large increases in input resistance that were more important in dendritic (approximately 50%) than somatic (approximately 10%) impalements. These findings imply that in the intact brain, pyramidal neurons are submitted to an intense spike-independent synaptic bombardment that decreases the space constant of the cells. These results should be taken into account when extrapolating in vitro findings to intact brains.

Integrin expression in non-small cell carcinoma of the lung.

Alteration of integrin expression in a number of different malignant diseases has been recognized, with a trend of downregulation of collagen-laminin binding integrin expression in epithelial tumor types noted. This study evaluated the expression of a panel of integrin subunits that included subunits that form receptors that bind to collagen and laminin (alpha 2, alpha 3, alpha 6 beta 4) and subunits that form receptors that bind to fibronectin and fibrinogen (alpha 5, alpha V, beta 3, beta 6) in 51 specimens of non-small cell carcinoma (NSCCA) of the lung by use of immunohistochemistry. Integrin expression was then correlated with histologic type (squamous vs. adenocarcinoma), absence or presence of hilar or mediastinal nodal metastasis at resection, and cellular differentiation (well or poorly differentiated). In general, downregulation of the collagen-laminin binding subunits was noted in tumor cells of the NSCCA specimens when compared to the progenitor normal bronchial epithelium. No differences were noted in integrin expression between squamous cell and adenocarcinoma or between node-positive or node-negative tumors. However, downregulation of the integrin subunit alpha 3 was noted to be significantly more common in poorly differentiated tumors (p = 0.02) and several of the other collagen-laminin binding subunits also appeared to be more downregulated in poorly differentiated tumors. No upregulation was seen in the alpha 5 subunit of the fibronectin receptor or the beta 3 subunit of the vitronectin receptor, however, approximately 50% of tumors showed upregulation of the beta 6 subunit, the great majority of these being well-differentiated, node-negative tumors. Downregulation of the collagen-laminin integrins may thus be associated with differentiation of NSCCA, but not metastasis, and may serve as an adjunctive prognostic marker of disease. The beta 6 subunit appears to be associated with malignant transformation, but may serve as a positive prognostic factor.

Fungal pulmonary abscess in an adult secondary to hyperimmunoglobulin E (Job's) syndrome.

Job's syndrome is characterized by recurring bacterial infections of the skin and sinopulmonary tract. Laboratory evaluation reveals consistent elevation of circulating immunoglobulin E levels. The syndrome has been reported as a rare cause of bacterial pulmonary abscess and pneumatocele formation in childhood; here we present a case of cavitating fungal abscess in an adult with Job's syndrome.

Transposable elements as plant transformation vectors for long stretches of foreign DNA.

The production of transgenic plants is now routine for most crops. However, using currently available transformation methods it is still difficult and time-consuming to obtain a collection of transformed individuals containing single or low-copy-number, intact transgenic inserts. Here we describe a set of broad-hostrange transformation vectors based on the Ac/Ds transposition system that improve both transformation efficiency and the quality of transgenic loci. These vectors efficiently deliver long stretches of foreign DNA into the genome, leading to transgenic strains containing an intact single-copy insert of 10kb. This type of vector could be an important additional tool for the production of transgenic plants with the well-defined, foreign DNA inserts required for biosafety approval and commercialisation.

Stress-induced intrachromosomal recombination in plant somatic cells.

Levels of induced homologous recombination between chromosomal repeats in plant somatic cells were examined. Transgenic plants of Nicotiana tabacum hemi- or homozygous for pairs of deletion derivatives of the neomycin phosphotransferase (nptII) marker gene integrated at a single genomic locus were produced. Homologous recombination within the overlapping parts of the nptII gene restored the function and the resulting kanamycin resistance was used for scoring recombination frequency. The recombination events were confirmed by the appearance of a characteristic 1245-base-pair EcoRV fragment detected in all kanamycin-resistant clones tested. The rate of spontaneous recombination was found to be related to the copy number of recombination substrates and was 9 x 10(-5) and 19 x 10(-5) for hemi- and homozygote strains, respectively. Ionizing radiation, mitomycin C, and heat shock markedly increased the frequency of intrachromosomal recombination. Low doses of x-rays (1.25 Gy) enhanced the relative recombination frequency to approximately twice the spontaneous value. The presence of mitomycin C increased the frequency of recombination 9-fold and exposure to an elevated temperature (50 degrees C) increased it 6.5-fold. The x-ray and heat shock treatments reduced cell viability to 53% and 8%, respectively. Mitomycin C treatment had no effect on cell survival.

Comparative gastrointestinal blood loss associated with placebo, aspirin, and nabumetone as assessed by radiochromium (51Cr).

Nabumetone differs from most other nonsteroidal anti-inflammatory drugs. It is presented to the gut as a nonacidic prodrug, and is metabolized to its active form after absorption. Studies in animals and humans suggest it is less irritating to the gastrointestinal mucosa. This study compared the gastrointestinal microbleeding induced by nabumetone to aspirin (acetylsalicylic acid, ASA), and placebo in a double blind parallel study using chromium 51Cr labelled red cells to quantitate fecal blood loss (FBL) in healthy volunteers. Thirty subjects were randomized to treatment with nabumetone (2000 mg), ASA (3.6 g) or placebo for 21 days following a 7 day placebo period. Six subjects served as untreated controls. FBL in nabumetone treated subjects was not significantly different to placebo or untreated subjects. In contrast, ASA-treated subjects exhibited significantly increased FBL than the other 3 groups (P less than .0001).