Recommendations for screening, monitoring, prevention, and prophylaxis of infections in adult and pediatric patients receiving CAR T-cell therapy: a position paper.

Chimeric antigen receptor (CAR) T-cell therapy is one of the most promising emerging treatments for B-cell malignancies. Recently, two CAR T-cell products (axicabtagene ciloleucel and tisagenlecleucel) have been approved for patients with aggressive B-cell lymphoma and acute lymphoblastic leukemia; many other CAR-T constructs are in research for both hematological and non-hematological diseases. Most of the patients receiving CAR-T therapy will develop fever at some point after infusion, mainly due to cytokine release syndrome (CRS). The onset of CRS is often indistinguishable from an infection, which makes management of these patients challenging. In addition to the lymphodepleting chemotherapy and CAR T cells, the treatment of complications with corticosteroids and/or tocilizumab increases the risk of infection in these patients. Data regarding incidence, risk factors and prevention of infections in patients receiving CAR-T cell therapy are scarce. To assist in patient care, a multidisciplinary team from hospitals designated by the Spanish Ministry of Health to perform CAR-T therapy prepared these recommendations. We reviewed the literature on the incidence, risk factors, and management of infections in adult and pediatric patients receiving CAR-T cell treatment. Recommendations cover different areas: monitoring and treatment of hypogammaglobulinemia, prevention, prophylaxis, and management of bacterial, viral, and fungal infections as well as vaccination prior and after CAR-T cell therapy.

Reference-mean-centered statistical quality control.

Background: Statistical quality control (SQC) procedures generally use rejection limits centered on the stable mean of the results obtained for a control material by the analyzing instrument. However, for instruments with significant bias, re-centering the limits on a different value could improve the control procedures from the viewpoint of patient safety. Methods: A statistical model was used to assess the effect of shifting the rejection limits of the control procedure relative to the instrument mean on the number of erroneous results reported as a result of an increase in the systematic error of the measurement procedure due to an out-of-control condition. The behaviors of control procedures of type 1ks (k = 2, 2.5, 3) were studied when applied to analytical processes with different capabilities (σ = 3, 4, 6). Results: For measuring instruments with bias, shifting the rejection limits in the direction opposite to the bias improves the ability of the quality control procedure to limit the risk posed to patients in a systematic out-of-control condition. The maximum benefit is obtained when the displacement is equal to the bias of the instrument, that is, when the rejection limits are centered on the reference mean of the control material. The strategy is sensitive to error in estimating the bias. Shifting the limits more than the instrument's bias disproportionately increases the risk to patients. This effect should be considered in SQC planning for systems running the same test on multiple instruments. Conclusions: Centering the control rule on the reference mean is a potentially useful strategy for SQC planning based on risk management for measuring instruments with significant and stable uncorrected bias. Low uncertainty in estimating bias is necessary for this approach not to be counterproductive.

Impact of prematurity and immigration on neonatal screening for sickle cell disease.

BACKGROUND: Others have described a relationship between hemoglobin A levels and gestational age, gender and ethnicity. However, studies are needed to determine normal cut-off points considering these factors. To address this issue we designed a study to determine the percentiles of normality of neonatal hemoglobin A levels taking these factors into account. METHODS: This cross-sectional study involved 16,025 samples for sickle cell disease screening in the province of Alicante, Spain, which has a high immigration rate. The primary variable was hemoglobin A, and the secondary variables were gender, gestational age (preterm and full term) and maternal origin (Spain, the rest of Europe, North Africa, Sub-Saharan Africa, Latin America and Asia). Percentiles of normality (1 and 99) were obtained by origin, gender and gestational age using quantile regression models and bootstrap samples. The association between these percentiles of normality and altered levels (≥1%) of hemoglobin E was analyzed. We obtained the percentiles of normality (1 and 99) for each maternal origin, gender and gestational age. RESULTS: Of a total of 88 possible E carriers, 65 had above-normal hemoglobin A levels (74%). The levels of normality for hemoglobin A varied greatly according to the maternal origin and gestational age. CONCLUSION: With the levels of normality that we established it is possible to discard samples with unrecorded blood transfusions. Our methodology could be applied to other diseases in the neonatal screening.