Overcoming the challenges of primary resistance and relapse after CAR-T cell therapy.

INTRODUCTION: While CAR T-cell therapy has led to remarkable responses in relapsed B-cell hematologic malignancies, only 50% of patients ultimately have a complete, sustained response. Understanding the mechanisms of resistance and relapse after CAR T-cell therapy is crucial to future development and improving outcomes. AREAS COVERED: We review reasons for both primary resistance and relapse after CAR T-cell therapies. Reasons for primary failure include CAR T-cell manufacturing problems, suboptimal fitness of autologous T-cells themselves, and intrinsic features of the underlying cancer and tumor microenvironment. Relapse after initial response to CAR T-cell therapy may be antigen-positive, due to CAR T-cell exhaustion or limited persistence, or antigen-negative, due to antigen-modulation on the target cells. Finally, we discuss ongoing efforts to overcome resistance to CAR T-cell therapy with enhanced CAR constructs, manufacturing methods, alternate cell types, combinatorial strategies, and optimization of both pre-infusion conditioning regimens and post-infusion consolidative strategies. EXPERT OPINION: There is a continued need for novel approaches to CAR T-cell therapy for both hematologic and solid malignancies to obtain sustained remissions. Opportunities for improvement include development of new targets, optimally combining existing CAR T-cell therapies, and defining the role for adjunctive immune modulators and stem cell transplant in enhancing long-term survival.

Sorption-oxidation mechanism for the removal of arsenic (III) using Cu-doped ZnO in an alkaline medium.

1-D oxides Zn1-xCuxO and spherical composites Zn1-xCuxO/CuO were obtained by thermolysis of formate-glycolate complexes Zn1-xCux (HCOO)(OCH2CH2O)1/2 (0 ≤ x ≤ 0.15). The structural and property characteristics showed that Cu was introduced into the Zn site of the ZnO lattice to form the Zn0.95Cu0.05O solid solution. The concentration of copper in the precursors regulates the topological and structural features of the formation of Zn1-xCuxO oxides, which determine their sorption and photocatalytic properties. The materials were tested in As3+ photooxidation reaction under UV and visible radiation. It has been established that Cu+ is an effective dopant in the composition of 1-D oxide Zn1-xCuxO (0 ≤ x < 0.1). The presence of Cu2+ in the shell of Zn1-xCuxO/CuO composite reduces the photoactivity of the material. The maximum efficiency of arsenic extraction (up to 80% for Zn0.95Cu0.05O) was achieved from dilute arsenic-containing solutions (3.8 mg/L As) and an adsorbent concentration of 0.8 g/L for 24 h. In saturated solutions (380 mg/L As) this value is reduced by a factor of 100. According to XPS data, the primary process is As3+ sorption on the catalyst surface followed by its oxidation to As5+. Using the EPR method it was found that singly charged oxygen vacancies V O + $$ {V}_O^{+} $$ associated with Cu in Zn1-xCuxO are directly involved in the photostimulated oxidation of As3+. PRACTITIONER POINTS: Two types of Zn1-x Cux O photocatalysts were obtained by thermolysis of the Zn1-x Сux (HCOO)(OCH2 CH2 O)1/2 complex (0 ≤ x ≤ 0.15) in air. Sorption of arsenic from dilute solutions reaches 80% on 1-D oxide Zn0.95 Cu0.05 O. Sorption of As3+ on the catalyst surface is at primary process followed by its oxidation to As5+ . Removal of As3+ from alkaline solutions occurs due to successful combination of sorption and photocatalytic properties of the 1-D oxides Zn1-x Cux O.

Evolution of the Microstructure and Phase Composition of the Products Formed in the Reaction between Iridium and W2B.

In the present study, we perform a systematic examination of the products formed by mixing and heating of tungsten boride and iridium powders at different ratios in a broad temperature range using qualitative and quantitative X-ray analysis and time-of-flight neutron diffraction (TOF-ND), in combination with scanning electron microscopy/energy-dispersive spectroscopy (SEM/EDS) performed at different accelerating voltages. The well-known and unknown ternary W-Ir-B phases were detected. The Vickers microhardness value for the new ternary W2Ir5B2 boride was measured. Based on these findings, the ternary W2Ir5B2 boride can be considered hard.

Successful Drug Desensitization to Ustekinumab in a Patient with Crohn's Disease.

Ustekinumab is a monoclonal antibody used as treatment for various inflammatory conditions. We present a pediatric patient with Crohn's disease who did not tolerate infliximab and was then changed to ustekinumab. He developed anaphylaxis to the medication after the second dose. A drug desensitization protocol was created by the allergy team leading to successful administration of both intravenous and then subcutaneous ustekinumab. As monoclonal agents become mainstays of therapy for inflammatory conditions, there are increased reports of allergic reactions. Prior reports and protocols of ustekinumab desensitization have not been reported. This case report highlights successful desensitization to ustekinumab as well as the importance of a multidisciplinary approach to addressing treatment needs of patients who develop life-threatening reactions to such medications.

Isolated B-cell lymphopenia and autoimmune hemolytic anemia as a curious combination of findings at the time of advanced Hodgkin lymphoma diagnosis: a pediatric case report.

Lymphopenia is associated with poor outcome in Hodgkin lymphoma (HL), but the impact of specific cytopenias is unexplored. We report a case of isolated B-cell lymphopenia with HL, EBV infection, and autoimmune hemolytic anemia (AIHA). Our patient is a 19-year-old male without any significant past medical history who presented with two weeks of epigastric abdominal pain, subjective fevers, night sweats, fatigue and a five-pound weight loss. At presentation, he had a white blood cell count of 10.3 k/uL and positive Coombs with a panagglutinin. Infectious testing was negative for HIV but positive for EBV. Peripheral lymphocyte flow cytometry identified 2% CD19+ cells with an absolute count of 43 cells/uL. This profound B-cell lymphopenia persisted despite the EBV viral load diminishing to barely detectable levels of less than 28 copies/mL. Computed tomography (CT) scan of the chest, abdomen and pelvis identified diffuse mediastinal and abdominal lymphadenopathy, as well as hepatosplenomegaly with focal lesions in the liver and spleen. A periaortic lymph node biopsy was morphologically consistent with Classical Hodgkin Lymphoma, Mixed Cellularity subtype (CHL, MC). Diagnosed with CHL, stage IVB, he was treated with the standard combination therapy of cyclophosphamide, doxorubicin, vincristine, bleomycin, prednisone, and etoposide, and he achieved a complete remission. This case highlights the unique presentation of isolated B cell lymphopenia and autoimmune hemolytic anemia in a young patient with HL.

Variable Presentation of the CYBB Mutation in One Family, Approach to Management, and a Review of the Literature.

Chronic granulomatous disease (CGD) is a primary immunodeficiency disorder marked by abnormal phagocytic function. CGD affects primarily neutrophils and manifests as an early predisposition to severe life-threatening infections. Additionally, patients with CGD are predisposed to unique autoimmune manifestations. While generally spared from infectious complications, heterozygous carriers of the abnormal genes implicated in CGD pathogenesis can still present with autoimmune disorders. A mutation in the CYBB gene is the only X-linked variant of this disease. This article describes a family with the CYBB mutation, its heterogenous presentation, and reviews the literature discussing disease management.

Retrospective Analysis of a New York Newborn Screen Severe Combined Immunodeficiency Referral Center.

In 2010, the New York State (NYS) Newborn Screen (NBS) Program added the T cell receptor excision circle (TREC) assay to screen for severe combined immunodeficiency disorder (SCID). The objective of this study was to perform a retrospective chart review of 199 infants referred to a single institution for abnormal TREC on NYS NBS between 2010 and 2017. Statistical analysis included analysis of variance, logistic regression models, chi-square, and linear mixed models. One hundred ninety-nine infants were found to have a TREC value of fewer than 200 copies/µL on NYS NBS. Infants were stratified as primary immunodeficiency (PID) (n = 54), immunocompetent (n = 133), lost to follow-up (n = 8), or deceased (n = 4). PID included SCID (n = 3), DiGeorge (n = 6), idiopathic lymphopenia (IL) (n = 44), and other syndromes associated with lymphopenia (n = 3). The 3 SCID cases were identified and brought to treatment, although all experienced significant infections. The study population was found to be predominately non-Hispanic, African American, and male. There was a difference in the average TREC values among those with immunocompetence (83 copies/µL), IL (81 copies/µL), and PID (40 copies/µL) (p < 0.05). On follow-up of 40 patients with IL, patients typically did not have severe infections during first few years of life. This study demonstrates that TREC value can be used to stratify infants for further confirmatory testing to exclude PID. Risk factors, such as stressful prenatal/postnatal conditions, prematurity, race, and sex may affect TREC value but cannot explain all causes of lymphopenia. This study may assist providers in risk stratifying the likelihood of PID with an abnormal TREC and determining the extent of the initial work up that is necessary at the time of a newborn's presentation.

Understanding the immunology of asthma: Pathophysiology, biomarkers, and treatments for asthma endotypes.

Asthma is a common disease in paediatrics and adults with a significant morbidity, mortality, and financial burden worldwide. Asthma is now recognized as a heterogeneous disease and emerging clinical and laboratory research has elucidated understanding of asthma's underlying immunology. The future of asthma is classifying asthma by endotype through connecting discernible characteristics with immunological mechanisms. This comprehensive review of the immunology of asthma details the currently known pathophysiology and clinical practice biomarkers in addition to forefront biologic and targeted therapies for all of the asthma endotypes. By understanding the immunology of asthma, practitioners will be able to diagnose patients by asthma endotype and provide personalized, biomarker-driven treatments to effectively control patients' asthma.

Considerations for hematopoietic stem cell transplantation in primary immunodeficiency disorders.

Primary immunodeficiency disorders (PIDs) result from inborn errors in immunity. Susceptibility to infections and oftentimes severe autoimmunity pose life-threatening risks to patients with these disorders. Hematopoietic cell transplant (HCT) remains the only curative option for many. Severe combined immunodeficiency disorders (SCID) most commonly present at the time of birth and typically require emergent HCT in the first few weeks of life. HCT poses an unusual challenge for PIDs. Donor source and conditioning regimen often impact the outcome of immune reconstitution after HCT in PIDs. The use of matched or unmatched, as well as related versus unrelated donor has resulted in variable outcomes for different subsets of PIDs. Additionally, there is significant variability in the success of engraftment even for a single patient's lymphocyte subpopulations. While certain cell lines do well without a conditioning regimen, others will not reconstitute unless conditioning is used. The decision to proceed with a conditioning regimen in an already immunocompromised host is further complicated by the fact that alkylating agents should be avoided in radiosensitive PIDs. This manuscript reviews some of the unique elements of HCT in PIDs and evidence-based approaches to transplant in patients with these rare and challenging disorders.

Primary Immunodeficiency with Severe Multi-Organ Immune Dysregulation.

Polyglandular autoimmune syndrome type 1, also known as autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), is a rare primary immunodeficiency disorder with multi-organ involvement. Besides for being predisposed to severe life-threatening infections, patients with APECED are also prone to organ impairment secondary to severe autoimmunity. As this is an autosomal recessive disorder, a biallelic mutation in the AIRE gene is responsible for APECED. The author presents a case of APECED with a single AIRE mutation. Whole exome sequencing identified a mutation in the BTNL2 gene that the author suggests may have contributed to the patient's presentation.

Immune Dysregulation in the Pathogenesis of Atopic Dermatitis.

Atopic dermatitis is a multifactorial disease. Epidermal barrier impairment often plays the initial role in the initiation of the disease. Immune dysregulation of the innate and adaptive immunity plays a central role in the pathogenesis of atopic dermatitis. Alteration of the epidermal microbiome-host interaction serves a catalytic role in propagating this immune response. The understanding of this disease pathogenesis is important in generating treatment options, especially those such as biologic agents that can target a specific immune pathway.

Pollen-induced antigen presentation by mesenchymal stem cells and T cells from allergic rhinitis.

Mesenchymal stem cells (MSCs) are promising cellular suppressor of inflammation. This function of MSCs is partly due to their licensing by inflammatory mediators. In cases with reduced inflammation, MSCs could become immune-enhancer cells. MSCs can suppress the inflammatory response of antigen-challenged lymphocytes from allergic asthma. Although allergic rhinitis (AR) is also an inflammatory response, it is unclear if MSCs can exert similar suppression. This study investigated the immune effects (suppressor vs enhancer) of MSCs on allergen-stimulated lymphocytes from AR subjects (grass or weed allergy). In contrast to subjects with allergic asthma, MSCs caused a significant (P<0.05) increase in the proliferation of antigen-challenged lymphocytes from AR subjects. The increase in lymphocyte proliferation was caused by the MSCs presenting the allergens to CD4(+) T cells (antigen-presenting cells (APCs)). This correlated with increased production of inflammatory cytokines from T cells, and increased expressions of major histocompatibility complex (MHC)-II and CD86 on MSCs. The specificity of APC function was demonstrated in APC assay using MSCs that were knocked down for the master regulator of MHC-II transcription, CIITA. The difference in the effects of MSCs on allergic asthma and AR could not be explained by the sensitivity to the allergen, based on skin tests. Thus, we deduced that the contrasting immune effects of MSCs for antigen-challenged lymphocytes on AR and allergic asthma could be disease specific. It is possible that the enhanced inflammation from asthma might be required to license the MSCs to become suppressor cells. This study underscores the need for robust preclinical studies to effectively translate MSCs for any inflammatory disorder.

SHG in doped GaSe:In crystals.

Optical transmission range and phase matching (PM) conditions for second harmonic generation (SHG) of Er3+:YSGG and CO2 laser in indium doped GaSe:In(0.1, 1.23, 2.32 mass%) are studied in comparison with these in pure and sulfur doped GaSe:S(0.09, 0.5, 2.2, 3 mass%) crystals. No changes in transparency curve are found in GaSe crystals up to 2.32 mass% indium content, but as small change as 0.18 degrees in PM angle for 2.79 microm Er3+:YSGG laser SHG and approximately 0.06 degrees for 9.58 microm CO2 laser emission line SHG are detected. PM properties of the crystals are evaluated as a function of temperature over the range from -165 to 230 degrees C. The value of dtheta/dT, the change in PM angle with variation of temperature, is found to be very small for GaSe:In crystals. While for SHG of Er3+:YSGG laser, dtheta/dT =22"/1 degrees C only, it is as small as -4.9"/1 degrees C for that of CO2 laser radiation. Linear variation of PM angle with temperature increasing is an indicator of absence of crystals structure transformation within temperature range from -165 to 230 degrees C. Thus, application of GaSe:In solid solutions in high average power nonlinear optical systems seems to be prospective.

Inducible nitric oxide synthase mediates prostaglandin h2 synthase nitration and suppresses eicosanoid production.

Nitric oxide (NO) modulates the biological levels of arachidonate-derived cell signaling molecules by either enhancing or suppressing the activity of prostaglandin H(2) isoforms (PGHS-1 and PGHS-2). Whether NO activates or suppresses PGHS activity is determined by alternative protein modifications mediated by NO and NO-derived species. Here, we show that inducible NO synthase (iNOS) and PGHS-1 co-localize in atherosclerotic lesions of ApoE(-/-) mouse aortae. Immunoblotting and immunohistochemistry revealed Tyr nitration in PGHS-1 in aortic lesions but markedly less in adjacent nonlesion tissue. PGHS-2 was also found in lesions, but 3-nitrotyrosine incorporation was not detected. 3-Nitrotyrosine formation in proteins is considered a hallmark reaction of peroxynitrite, which can form via NO-superoxide reactions in an inflammatory setting. That iNOS-derived NO is essential for 3-nitrotyrosine modification of PGHS-1 was confirmed by the absence of 3-nitrotyrosine in lesions from ApoE(-/-)iNOS(-/-) mice. Mass spectrometric studies specifically identified the active site residue Tyr385 as a 3-nitrotyrosine modification site in purified PGHS-1 exposed to peroxynitrite. PGHS-mediated eicosanoid (PGE(2)) synthesis was more than fivefold accelerated in cultured iNOS(-/-) versus iNOS-expressing mouse aortic smooth muscle cells, suggesting that iNOS-derived NO markedly suppresses PGHS activity in vascular cells. These results further suggest a regulatory role of iNOS in eicosanoid biosynthesis in human atherosclerotic lesions.