Time Of Expansion Research Articles

The cost of readmissions in hospitals: the case of the Spanish public hospitals

BackgroundIn this paper, we propose a novel model that allows us to understand the effect of hospital readmissions on technology and costs. To do this, we consider that hospitals may experience heterogeneous discharges: on the one hand, discharges corresponding to patients who have completed their healing process in hospital and, on the other hand, discharges resulting from patients who have been discharged too early and are therefore required to be readmitted to hospital. In the first case, discharges involve more resources; in the second case, the patient returns implying an additional use of resources. In tandem, two new issues arise which need to be addressed: a) Does a trade-off exist between the decision to discharge at the finalisation of fully completed treatment or the decision to discharge taken at an earlier stage; b) Readmissions may prove endogenous and if so, their econometric treatment must be considered in order to obtain unbiased results. Our study contributes to the literature by proposing a novel model which estimates the marginal cost of readmissions, thus allowing us to understand the effect of readmission on technology and hospital costs.MethodsTo resolve the foregoing concerns, this paper proposes a theoretical and empirical model based on the dual theory, which combines cost and input-oriented distance functions to obtain the marginal cost of readmissions. Our empirical application uses a panel of Spanish public hospitals observed over the period 2002–2016.ResultsResults indicate that the treatment required by a patient who is readmitted proves more expensive than keeping the patient under observation for a few extra days in order to achieve a definitive discharge. Moreover, this additional cost follows an increasing temporal trend, especially in times of expansion when the availability of resources is greater.ConclusionsGiven that the results indicate that readmissions imply an additional cost for the hospital system, they must be contained. In fact, readmission rates are a significant component of current hospital sector activity improvement strategies. Therefore, knowing the cost which readmission implies is relevant for the design of policies that seek to penalize those hospitals with high readmission rates.

Prediction of the effective diffusion coefficient on sulfate ions in heterogeneous concrete based on Mori-Tanaka scheme

The interfacial transition zone (ITZ) between the aggregates and the matrix in concrete is the main reason for the low prediction accuracy of the effective diffusion coefficient of sulfate ions in concrete. To solve this problem, a new multi-scale prediction model of the effective diffusion coefficient for the transport of sulfate in concrete was established based on the Mori-Tanaka scheme, which fully reflects the characteristics of the imperfect ITZ, the morphological characteristics of the aggregates, the aggregate grading, and the time-varying characteristics of the content of the ITZ, the porosity and the tortuosity of the pore structure. The results showed that the prediction results of the model were basically consistent with the experimental and literature results, and the maximum error was only 20.43 %. In addition, taking the commonly used strength grades C30 and C50 concrete in engineering as examples, the changes in effective diffusion coefficient under different concentrations of sulfate erosion were predicted, showing a trend of first decreasing, plateauing, then increasing, and objectively reflecting the objective law of sulfate transport-reaction-filling-expansion damage in concrete. The predicted results confirmed that at the concentration of 3 % Na2SO4 solution, the starting time of expansion for C50 concrete is approximately 3 years later than that for C30 concrete, verifying that enhancing the concrete's strength grade significantly improves its sulfate corrosion resistance.

Medicaid expansion and opioid prescriptions: Evidence from the Medical Expenditure Panel Survey.

Evidence is mixed on whether increased access to insurance, specifically through the ACA's Medicaid expansion, exacerbated the opioid public health crisis through increased opioid prescribing. Using survey data on retail prescription drug fills from 2008 to 2019, we did not find a significant relationship between Medicaid expansion and opioid prescribing in the newly eligible Medicaid population. It may be that the dangers of opioids were known well enough by the time of the Medicaid expansion that lack of access to care was no longer a binding constraint on opioid prescription receipt.

Ichthyocenosis of the upper epipelagic layer in the Pacific waters of Russia during japanese sar-dine «renaissance» in the beginning of the 21<sup>st</sup> century

Dynamics of integral parameters for the species structure in ichthyocenosis of the upper epipelagic layer in the Pacific waters off the Kuril Islands in 2019–2023 is discussed in compare with previously published data since 2004 in context of a new bloom of japanese sardine Sardinops melanostictus. Results of trawl surveys are clustered using the method of multi-dimensional scaling. Species composition in the trawl catches in 2004–2013, before the time of mass expansion of subtropi-cal migrants, as japanese sardine and chub mackerel Scomber japonicus, was distinguished by domina-tion of mesopelagic fishes of families Myctophidae and Microstomatidae and pink salmon Oncorhynchus gorbuscha. From 2014 to the present, the dominant positions in the ichthyocenosis were held by japanese sardine and chub mackerel, with a decreasing role of the latter. In the last pentade (2019–2023), the species structure of pelagic ichthyocenosis in the Pacific waters of Russia has not undergone fundamental changes. At the same time, the tendency has increased for uneven distribution of biomass between the species of fish community in favor of japanese sardine. The polydominance index decreased significantly (P < 0.05, t-test 4.33) from 4.85 ± 0.44 in 2004–2013 to 2.37 ± 0.21 in 2019–2022, and the index of evenness of species structure decreased from 0.41 ± 0.04 to 0.15 ± 0.02 (P < 0.05, t-criterion 5.25). Growth of domestic and foreign catches of japanese sardine in the second decade of the 21 century is a sign of this species bloom beginning.

The effect of labour migration and structural changes on economic development

The article aims to analyze effects of the labour migration and structural changes on economic development. The Russian invasion in Ukraine increased geopolitical risks for the global economy in 2022 and in the present time. The most immediate economic impact of the Ukrainian conflict was sharply rising food, energy, and commodity prices in the world. In the process of massive population displacement people were forced to leave their homes and lose their livelihood. The analysis of basic approaches to the effects of labour migration, and structural changes on global development highlights the contemporary challenges for the current institutional and structural setting of the economies and societies. The current global crisis is likely to have deep-reaching effects that we cannot foresee. It has been mistaken to believe that migrants will serve as a safety valve for developed economies, by providing labour in times of expansion and going away in the recession (Castles & Vezzoli, 2009). The assessment of structural change on the inclusiveness and sustainability of socioeconomic development depends on the specific country. Both the relative supply of skills and skill-based technological change tends to increase income inequality, though not in all countries (Nomaler et al., 2021). The study of the impacts of international emigration on the evolution of the institutions in the origin countries demonstrates the influence of emigration per se (i.e., people who left the country can voice from abroad), and the transfer of the norms of the host country to the home country. The existence of both impacts was confirmed using different indicators of institutional quality. The effects appear stronger when skilled emigration is considered (Beine & Sekkat, 2013). It is proposed that new job structures based on hiring the low-cost labour will appear under the effects of increasing labour migration. One of the decisions could be adoption by policymakers of new systems of global migration governance based on international collaboration and the rule of law by taking lessons from the crisis experience. It will be directed to define sectors that can speed up the process of rebuilding the global economy. Diversifying the economy, increasing product/service sophistication, using comparative advantages and transfer of resources (both labour and capital) leads to more productive activities and a rise in well-being.

In a time of theoretical expansion and change, don’t throw babies out with the bath water

ABSTRACT Various challenges faced by the psychoanalyst when moving from “on the couch” work to “off the couch” work are raised and discussed. It is argued that the biggest challenges concern methodology: what now constitutes the analytic setting and field, and what counts as analytic data? The author describes some of the methodological challenges she has faced so far in studying climate change denial at individual, group, cultural and political levels. She raises potential pitfalls with “off the couch” work, that include overgeneralisations and assuming one can directly apply insights gained “on the couch” to wider contexts. In conclusion, she reflects that her training and practice working with individuals on the couch has proved bedrock in working “off the couch”.

Quality Assessment of Metabolic Fitness during T Cell and NK Cell Expansion

Abstract CAR-T cells have revolutionized cancer treatment, and other cell types like CAR-NK cells are also showing promising results. Engineered cells generally need to be expanded ex vivo before being transfused into patients. Growth conditions, including expansion platform, cell culture media, and cytokine composition, time of expansion, etc., can have a strong effect on the characteristics of the final products and need to be monitored to establish the appropriate development process. Recent developments highlight the significance of cell metabolism in influencing immune responses and the anti-tumor efficacy of cell therapies. In the present study, we utilized Seahorse XF technology and assays to characterize T cell and NK cell metabolic fitness during cell expansion. We cultured human T cells and NK cells under different expansion conditions including culture media, culture devices, and cytokine combinations, and sampled cells at different time points for quality assessment of metabolic fitness. Using the new Seahorse XF assay alongside immunophenotypic characterization using Novocyte Flow Cytometry, we obtained robust information on mitochondrial and glycolytic energy production, metabolic poise, and the bioenergetic capacity of the expanded cells, allowing us to identify conditions that resulted in increased metabolic fitness of the cell population that can contribute to defining cell expansion conditions during immunotherapy development.

Abstract 3636: Myeloid cell rebound associated with GD2-CAR-T cell therapy in solid tumor patients

Abstract GD2 is a validated cancer immunotherapy target with highly restricted normal tissue expression. Promising activity of GD2-CAR-T cell therapy in diffuse midline glioma and neuroblastoma has promoted interest in this therapy. We initiated three phase 1 clinical trials of escalating doses of intravenously administered autologous GD2-CAR-T cells in patients with advanced GD2-positive solid tumors. Emerging evidence suggests that CAR-T cells may increase circulating myeloid derived suppressor cells (MDSCs) and that this event may be mediated and/or triggered by CAR-T cell-derived cytokines and chemokines. These findings may help to explain the limited persistence of CAR-T cell therapy in solid tumor patients. Hence, we sought evidence of MDSC generation and secretion of relevant cytokines and chemokines in our clinical trial patients. The CARPETS trial (www.anzctr.org.au: ACTRN12620000622909) recently closed to recruitment after enrolling 12 patients (7 melanoma, 4 colorectal cancer, and 1 sarcoma). No significant adverse events were attributable to CAR-T cell therapy. We opened two other GD2-CAR-T cell therapy trials in 2023: LEVI’S-CATCH (ACTRN12622000675729) in patients with diffuse midline glioma at Sydney Children’s Hospital and KARPOS (ACTRN12622001514796) in adult patients with recurrent glioblastoma at Royal Adelaide Hospital. To date, 3 patients have enrolled to LEVI’S-CATCH with the first patient clearing the dose limiting (DLT) evaluation period. Three patients completed enrolment to the first dose cohort of KARPOS without DLTs. In all CARPETS patients, CAR-T cell expansion, which was measured by by DNA quantitative PCR and flow cytometry, peaked during the 6-week post-CAR-T infusion DLT evaluation period. In 6 CARPETS patients for whom peripheral blood samples were available, we found by flow cytometry, newly formed or increased size of pre-existing subpopulations of non-classical monocytes and/or MDSCs of mononuclear and/or polymorphonuclear class, which peaked at or after the time of peak CAR-T cell expansion. Typically, serum levels of inflammatory cytokines and chemokines such as TNF, IL-6, IL-8, CCL2, GM-CSF, and CXCL10, were detected only after the CAR-T cell infusion with variable patterns of the timing and concentration of analyte observed among the 12 patients. At the time of writing, blood samples from the first KARPOS patient showed CAR-T cell expansion and the subsequent increases in circulating myeloid derived suppressor cells and inflammatory cytokines. We expect that full data sets for these parameters will be presented for current and future enrolled patients to both studies. To improve CAR-T cell persistence in solid tumor patients, these data indicate the need for new therapeutic strategies to mitigate effects of CAR-T cell induced myeloid cells with antitumor activity. Citation Format: Michael P. Brown, Tessa Gargett, Nga T. Truong, Orazio Vittorio, David S. Ziegler. Myeloid cell rebound associated with GD2-CAR-T cell therapy in solid tumor patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3636.

DESTRUCTION OF ROCKS BY EXPLOSION DURING OIL TRANSPORTATION

When oil and gas wells are ready for operation, when drilling is carried out at the bottom of the well to establish contact with the formation, it is considered that the degree of crushing of the rocks is proportional to the speed of application of the load. As a result of the stresses created by them, the degree of fragmentation is higher. In the article, it is proposed to take into account the quality of crushing of the necessary rock by using some empirical coefficients in the calculation formulas. The dynamics of the rock dispersion process is studied on the basis of the hydrodynamic hypothesis. Here, the solution of the system of differential equations is given based on the fundamental laws of conservation of mass, energy and momentum. Based on the strength properties of mountain rocks, broken lines are found in the continuum of the whole environment, which determines the final effect of rock crushing. However, the accepted assumptions about the incompressibility of the rock and the transfer of the explosive impulse to the immediate environment significantly reduce the practical value of the results. It should be noted that in the immediate area directly adjacent to the load, the mountain rock is under uneven volume compression. In this case, the largest tangential stresses occur mainly in planes oriented at an angle of 450 to the radial direction. Thanks to this, a system of spiral sliding lines breaks the rock into small blocks. Outside this zone, a system of radial cracks is formed as a result of the expansion of the massif. When the pressure in the gas cavity decreases and the mass moves back in the direction of the load, tangential cracks appear. The combination of the volume compression zone and the reach zone constitutes the controlled crushing area. When the compression wave reaches the bare surface, it becomes a stress wave. As this wave travels from the surface to the load, it forms a system of jump cracks. The high explosive effect of explosive gases with sufficient explosion energy causes the release of such shattered rock. Obviously, this concept is very important for the development of the theory of explosive disintegration of mountain rocks. Because there is no unequivocal relationship between the nature of the dissolution of the rock and the acoustic hardness. One of the first to clearly describe the mechanism of shock wave formation and its transformation into a more explosive and seismic wave when detonation reaches the boundary of the charge cavity. In rocks, shock waves are formed during the entire time of expansion of the gas cavity. It explains in detail the mechanism of cracking phenomena by considering the cracks as a source of multiple reflections of the stress wave. Keywords: rock strength, constant material, scale effect, rocks, destruction probability, fractured, robustness theory, microcrack, mineral, experience constant, density of defects, displacement, compression.

Pedostratigraphic age model for Devonian red beds of NW China

Detrital zircon geochronology has been used to determine provenance, but also gives maximum depositional ages that can constrain other forms of geochronology, such as magnetostratigraphy and pedostratigraphy. Pedostratigraphy and magnetostratigraphy correlate a series of global events by spacing or intensity in a fashion comparable with a commercial barcode. The Late Devonian Shaliushui Formation of NW China is poorly fossiliferous, but shows spikes in magnetic susceptibility, Al/Si ratios, Rb/Sr ratios and the depth to carbonate nodules (Bk horizon) corresponding with the timing of named Late Devonian black shale horizons. By contrast, the Ti/Al ratios show only small variations, indicating little long-term change in the source terrain or in the hydraulic sorting of heavy minerals. Most of the detrital zircon ages are older than an age model from the pedostratigraphic correlation of deep calcic horizons corresponding to global atmospheric CO 2 spikes at times of black shale expansion, but one detrital zircon age converges with the pedostratigraphic depositional ages near the top of the section. Pedostratigraphy is widely used in Quaternary sequences, but can also be a basis for age models of rocks in deep time if supported by detrital zircon ages. Supplementary material: Paleosol and geochemical data, and youngest zircon ages for a section of Devonian rocks near Ciyao, Gansu, China are available at https://doi.org/10.6084/m9.figshare.c.7008192

Contested port cities: Logistical frictions and civic mobilization in Genoa and Venice

This article examines the increasingly conflictual relationship between ports and their surrounding communities at a time of wide-reaching infrastructural expansion. It highlights how the centralization of power and logistical gigantism produce deterritorializing frictions, decoupling inhabitants from their territories and creating the conditions for social contestation. It calls for a rethinking of the role of communities in contemporary port-city governance, with an emphasis on imaginaries of re-territorialization produced through social mobilization. I frame the increasing contestation in port cities through a critical approach to logistics, arguing that citizen engagement holds the potential to drastically readdress the port-city relationship. It examines the cases of Genoa and Venice using ethnographic methods and reconstructs a historically in-depth counter-narrative of interactions between port, city and citizen. I contextualize specific frictions between port and city through the rise in social mobilizations. The article shows how social mobilization challenges the status quo in different ways, producing changes and illuminating pathways toward more sustainable forms of coexistence between ports and cities.

Government Expenditure and Economic Growth Nexus in Ghana

Purpose: Economic growth is widely regarded as a crucial indicator of economic advancement within a nation, as it has significant implications for the provision of state benefits, the improvement of living standards, and the generation of employment opportunities. The present study employed a time series analysis spanning from 1983 to 2018, focusing on Ghana, in order to comprehensively examine the diverse impact of both aggregate and disaggregated government expenditure and debt on the country's economic growth.
 Methodology: The study conducted initial examinations, including unit root tests, cointegration tests, and correlation matrices, to determine the statistical reliability and validity of the data series for the research. The long-run parameters were estimated using the two-stage least square regression method, the autoregressive distributed lag method, and the threshold regression method.
 Findings: Based on our research, it has been determined that government expenditure exerts a positive and statistically significant influence on overall economic growth. However, when examining the disaggregated effects, it becomes evident that consumption expenditure has a positive and significant impact on economic growth, whereas capital expenditure has a negative effect on economic growth.
 Unique Contribution to Theory, Practice and Policy (Recommendations): In relation to the prevailing economic conditions characterised by periods of prosperity or recession, it is evident that the government should prioritise its attention towards external debt rather than domestic debt during times of economic expansion. Moreover, during periods of economic downturn, it is imperative for the government to prioritise foreign direct investment as a means of financing its budget, rather than relying on debt

Nineteenth-Century Contextualization of “Race-Religion”

In her wide-ranging article, “An Imperial History of Race-Religion in International Law,” Rabiat Akande delves into the realms of history illustrating how the “race-religion” constellation became formative in current international law, specifically in Western discrimination toward minorities. As Akande writes, “the legacy of that past survives in the continuing interplay of the racial and religious othering of the non-Euro-Christian other.”1 This racialized-religious heritage, for instance, is evident in Western debates on the Hijab, Jewish circumcision (Brit Milah), and various other rituals practiced by religious minorities in the West. As a historian of the nineteenth century, in this essay I mainly focus on Akande's reconstruction of the historical aspect of the “race-religion” nexus. I begin by partially validating Akande's argument concerning the emergence of race-religion during the end of the nineteenth century, and by emphasizing Western racial discrimination against Islam and Judaism—the two “sister Semitic” religions. I then add what I see as important nuances that must be considered in the historical analysis of race-religion. Primarily, I illustrate how race-religion was “fluid” at times, allowing specific groups to “enter” Western civilization, while in other cases, race-religion was rigid, barring the inclusion of groups. Akande argues that the nineteenth century colonial expansion (in Africa, the Middle East, and India) dramatically contributed to the rise of the shared European categories of whiteness and Christianity. This emerging Western identity was antagonistic to the alleged “barbarism” of the non-whites and non-Christians. Nevertheless, further nineteenth-century inner-European contextualization is needed since the exclusion through race-religion also targeted, exactly at the time of this European imperial expansion, other “fellow Christian whites,” such as the Catholic Irish and Poles. It is not only “whiteness” per se that became prevalent, but a specific form of “whiteness” (e.g., Anglo-Saxon, Teutonic, Aryan) that was constantly reimagined and redefined.

Cosmological model free of singularity and inflation based on the large numbers hypothesis

It is shown that the new precise formulation of the Large Number Hypothesis (LNH), relating by means of the large number N_0 = 5.73×10^60 the modern cosmological parameters (age, size, mass, average density, and minimum temperature of the universe) with the corresponding Planck units, allows to determine the time course of these cosmological parameters during the expansion. It was found that the dimensions and mass of the universe increase linearly with time from Planck time t = t_P to the present day, starting from Planck values and increasing N_0 = 5.73×10^60 times to now. The amazing result was found that for each discrete time step (beat) with a unit Planck time ∆t = t_P, the size of the universe increases by one Planck length l_P and its mass increases by one Planck mass m_P. It is shown that the average density of the universe decreases proportionally to the square of time, and starting from the Planck density ρ_P ~ 10^96 kg m-3 decreases N_0^2 = 3.28×10^121 times to 9.46×10^-27 kg m-3 in the current epoch. The minimum measurable temperature, which is equal to the Hawking temperature for the universe T_H decreases linearly with time 5.73×10^60 times, and starting from the Planck temperature T_P = 10^32 K, it falls to 1.75×10^-29 K at the present time. It is shown that the found time course of cosmological parameters and the Planck values of the size, mass, average density, and temperature of the universe at the initial moment of the expansion t = t_P follow from the requirement to preserve the Euclidean geometry of space throughout the time of the cosmological expansion. Therefore, the suggested cosmological model based on the new formulation of LNH is free of singularity because the size and density of the universe remain finite/Planckian in the initial moments of its emergence. Besides, this model conserves the flatness and homogeneity of the universe during cosmological expansion and does not need an inflationary epoch in the early universe.

Analysis of Financial Statements of Listed Biotechnology and Materials Enterprises from the Perspective of Enterprise Strategy -- A Case Study of Huaxi Biology

As the notion of scientific skin care gains widespread acceptance, customers are displaying a growing interest in product ingredients and their precise benefits. As a result, it has been seen that local firms that specialize in skin care have been on a substantial growth trajectory over the past few years, signaling the beginning of a successful time of expansion. When compared to all other domestic brands, Huaxi Bio demonstrates an exceptionally prominent presence. This paper focuses on Huaxi Bio as the subject of the case study. This study examines the financial performance of Huaxi Bio by consolidating its financial data from 2019 to 2022. It specifically focuses on the analysis of the brand building investment, identification of prerequisites for Huaxi Bios success, evaluation of the impact of diversification strategy implementation on its financial performance, and proposes development suggestions for similar enterprises.

On the difficulty of validating molecular generative models realistically: a case study on public and proprietary data

While a multitude of deep generative models have recently emerged there exists no best practice for their practically relevant validation. On the one hand, novel de novo-generated molecules cannot be refuted by retrospective validation (so that this type of validation is biased); but on the other hand prospective validation is expensive and then often biased by the human selection process. In this case study, we frame retrospective validation as the ability to mimic human drug design, by answering the following question: Can a generative model trained on early-stage project compounds generate middle/late-stage compounds de novo? To this end, we used experimental data that contains the elapsed time of a synthetic expansion following hit identification from five public (where the time series was pre-processed to better reflect realistic synthetic expansions) and six in-house project datasets, and used REINVENT as a widely adopted RNN-based generative model. After splitting the dataset and training REINVENT on early-stage compounds, we found that rediscovery of middle/late-stage compounds was much higher in public projects (at 1.60%, 0.64%, and 0.21% of the top 100, 500, and 5000 scored generated compounds) than in in-house projects (where the values were 0.00%, 0.03%, and 0.04%, respectively). Similarly, average single nearest neighbour similarity between early- and middle/late-stage compounds in public projects was higher between active compounds than inactive compounds; however, for in-house projects the converse was true, which makes rediscovery (if so desired) more difficult. We hence show that the generative model recovers very few middle/late-stage compounds from real-world drug discovery projects, highlighting the fundamental difference between purely algorithmic design and drug discovery as a real-world process. Evaluating de novo compound design approaches appears, based on the current study, difficult or even impossible to do retrospectively.Scientific Contribution This contribution hence illustrates aspects of evaluating the performance of generative models in a real-world setting which have not been extensively described previously and which hopefully contribute to their further future development.

Effect on capillary refill time of volume expansion and increase of the norepinephrine dose in patients with septic shock

BackgroundCapillary refill time (CRT) has been suggested as a variable to follow during the course of septic shock. We systematically investigated the effects on CRT of volume expansion and norepinephrine.MethodsIn 69 septic shock patients, we recorded mean arterial pressure (MAP), cardiac index (CI), and 5 consecutive CRT measurements (video method, standardized pressure applied on the fingertip) before and after a 500-mL saline infusion in 33 patients and before and after an increase of the norepinephrine dose in 36 different patients. Fluid responders were defined by an increase in CI ≥ 15%, and norepinephrine responders by an increase in MAP ≥ 15%.ResultsThe least significant change of CRT was 23%, so that changes in CRT were considered significant if larger than 23%. With volume expansion, CRT remained unchanged on average in patients with baseline CRT < 3 s (n = 7) and in all but one patient with baseline CRT ≥ 3 s in whom fluid increased CI < 15% (n = 13 “fluid non-responders”). In fluid responders with baseline CRT ≥ 3 s (n = 13), CRT decreased in 8 patients and remained unchanged in the others, exhibiting a dissociation between CI and CRT responses. The proportion of patients included > 24 h after starting norepinephrine was higher in patients with such a dissociation than in the other ones (60% vs. 0%, respectively). Norepinephrine did not change CRT significantly (except in one patient) if baseline CRT was ≥ 3 s and the increase in MAP < 15% (n = 6). In norepinephrine responders with prolonged baseline CRT (n = 11), it increased in 4 patients and remained unchanged in the other ones, which exhibited a dissociation between MAP and CRT responses.ConclusionsIn septic shock patients with prolonged CRT, CRT very rarely improves with treatment when volume expansion increases cardiac output < 15% and increasing norepinephrine increases MAP < 15%. When the effects of fluid infusion on cardiac output and of norepinephrine on MAP are significant, the response of CRT is variable, as it decreases in some patients and remains stable in others which exhibit a dissociation between changes in macrohemodynamic variables and in CRT. In this regard, CRT behaves as a marker of microcirculation.Trial registration: ClinicalTrial.gov (NCT04870892). Registered January15, 2021. Ethics committee approval CE SRLF 21-25.

CTLA-4 Blockade Results in the Enrichment of Proliferative CD56 dimCD16 + NK Cells Following Infusion of Haploidentical Donor Memory-like Natural Killer Cells Plus IL-15 Superagonist in a Phase 1 Trial

Introduction Regulatory T cells (Tregs) blunt anti-tumor responses of major immune effector cells including CD8 T cells and natural killer (NK) cells. Tregs constitutively express CTLA-4 and thus the use of ipilimumab, a CTLA-4 blocker can potentially overcome the Treg-mediated immune suppression. We (and others) have shown that a brief activation of conventional NK cells with the cytokine combination IL-12, IL-15, and IL-18 generates cytokine-induced memory-like (CIML) NK cells which exhibit enhanced anti-tumor responses, have a longer half-life (up to 90 vs ~12 days of conventional NK cells), and show promising activity in several early phase clinical trials. N-803 is an IL-15 super-agonist with a long half-life that preferentially activates and expands NK and CD8+ T cells without affecting Tregs, making it an ideal cytokine for combining with adoptive immunotherapy. In the current study, we hypothesized the use of ipilimumab (IPI) will abrogate Treg-mediated inhibition and thus allow enhanced proliferation, activation, and anti-tumor responses of the adoptively transferred CIML NK cells.To address this, we conducted a phase 1 trial of HLA-haploidentical CIML NK cells in combination with IPI and N-803 in patients with advanced head and neck cancer (HNC). Using flow cytometry and CITE-Seq on the banked peripheral blood samples, we performed an in-depth characterization of NK cells expanded following IPI pre-exposure and compared it to those who did not receive IPI. Methods We enrolled 10 patients with refractory HNC regardless of human papillomavirus (HPV) status who had prior platinum and immunotherapy (NCT04290546). All patients received lymphodepletion with fludarabine (25 mg/m 2 x 5 days) and cyclophosphamide (60 mg/kg x 2 days) during days -6 to -2 prior to haploidentical CIML NK cell infusion on day 0 (5-10 x 10 6 cells/kg=dose level 0) followed by N-803 (15 mcg/kg subcutaneously) starting on day +1 every 21-days for 4-doses. In cohort 2, patients received IPI (3 mg/kg) on day -7, no ipilimumab was given to the first 6 patients treated on the lead-in safety cohort 1. Flow cytometry using a custom NK cell panel was performed on samples collected on days +7, +14, +21, +28, +42, and +60 after CIML NK cell infusion. FlowSOM clustering was performed on NK cell markers. UMAP clustering was applied to CITE sequencing data acquired from samples collected on day +7 and day +28, and well-defined markers genes for each cluster were used to identify cell populations. NK cell function (cytotoxicity, IFNg, and CD107a) was assessed using flow-cytometry based assays. Results The median age of the patients was 58, 90% were men and 80% had oropharyngeal primaries. Mild CRS (grade 2 or lower) was observed in 60% of patients. No neurotoxicity or graft-versus-host disease was observed. Maximal expansion of NK cells occurred on day +7 following CIML NK cell infusion in 9/10 of patients. The single patient without NK cell expansion was found to have a donor-specific anti-HLA antibody. Day +7 NK cells exhibited upregulation of IFNg expression following cytokine restimulation as compared to resting NK cells. Tumor regression was observed in 50% of treated patients at day +30 based on RECIST v1.1 criteria. Patients who had tumor regression had an expansion of CD56 dimCD16 + NK cell clusters by day +14. IPI treated patients were noted to have a relative enrichment of CD16 + NK cell metaclusters at day +14 compared to no IPI patients (Figure 1A). At the time of maximal NK cell expansion, CITEseq defined NK cell clusters were dominant in both IPI and no IPI patients, but the proliferative gene sets were enriched in the IPI treated patient (Figure 1B). IPI exposure had no effect on the distribution of regulatory T cells or CD8 + T cell populations at day +28 compared to the no IPI patients. Conclusions The use of donor-derived CIML NK cells is safe and associated with tumor regression in patients with advanced HNC. The use of IPI was associated with the preferential expansion of CD16 + NK cell clusters that had enrichment of proliferative gene sets. Tumor regression was associated with CD56 dimCD16 + NK cell expansion. Further work is required to elucidate the mechanism by which IPI exposure is associated with the expansion of specific subsets of CIML NK cells.

Relevant Studies on Cytokines Level and CAR-T Expansion Associated to CD7 CAR-T Therapy

Background In the past few years, CD7 became a highly reliable marker of CAR-T therapy treating T cell acute lymphocytic leukemia(T-ALL). In this case, better understanding of CD7 CAR-T therapy on cellular level became meaningful. Aim To figure out the correlation of cytokines level and CAR-T expansion to CRS and outcomes of CD7 CAR-T therapy. Methods Peripheral blood samples were collected from 70 patients treated with CD7 CAR-T from Dec. 2020 to Nov. 2022 in Hebei Yanda Ludaopei Hospital. There were 56 males and 14 females, from 2-year old to 60 with median age 19. Based on criteria of CRS and assessment results, 70 patients were split in different groups. According to CRS level, two groups were set as low (CRS0-1, 56 of 70) group and high group (CRS2-4, 14 of 70). Due to assessment results, 55 of 70 were classified as CR/CRi group, 15 of 70 were Non-CR group. 24 Cytokines (IL-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-17A, IL-17F, IL-22,TNFα, TNFβ, IFN-γ, IL-2RA/sCD25, MIP-1α, MCP-1, GM-CSF, IL-15, REG3a, Elafin, ST-2, Granzyme B, TNFRI) were measure with microbeads with 2 lasers 4 colour Calibur flow cytometer. CAR-T cells, target cells(CD7+ cells), T cells subsets(CD3+, CD4+, CD8+, CD8+TCM, CD8+TEM, Treg) were tested with 3 lasers 8-10 colour Canto flow cytometer. All the cellular variations were calculated by comparing value of peak-time to value of D0 which was used as baseline. Time points day0, 4, 7, 11, 14, 21, 30 were monitored after CAR-T infusion. FCM data was analyzed with Diva software. Prism 8 was used for statistic analyse. Results According to patient characteristics (shown in table 1a), no matter under which criteria, patients in all 4 groups had similar median age and transfection efficiency. First of all, based on criteria of CRS level, patients were split into low group and high group(upper table 1a). CAR-T peak time was appeared significantly later(p=0.0274) in high group. Along with that, in high group, CD8+TEM(effect memory T) cells was amplified significantly more than that in low group at peak time point(p=0.0258). Clearance rates of target cells(CD7+) in low group were significantly higher(p=0.003). According to cytokine secretion levels, the level of IL-4(p=0.0183), IL-6(p&amp;lt;0.0001), IL-8(p=0.043), IL-10(p&amp;lt;0.0001), IL-22(p=0.0463), IFN-γ(p&amp;lt;0.0001), sCD25(&amp;lt;0.0001), MCP-1(p=0.0092), IL-15(p=0.0029), Granzyme B(p=0.0027) were significant higher in high group(as shown in figure 1). All median peak time of those 10 cytokines in high group were calculated, from day 10 up to day 15 after CAR-T infusion. According to the time gap between each of 10 cytokines with CAR-T expansion, MCP-1 had the largest time gap, which means MCP-1 reached peak time 9 days earlier than that of CAR-T cells. The median peak-time gap between cytokines level with CAR-T cells expansion was 6 days(showed in table 1b). Secondly, due to criteria of assessment results of CD7 CAR-T therapies, 70 patients were classified as CR/CRi group and Non-CR group (lower table 1a). CAR-T expansion, T cell subsets variation showed no statistical difference between two groups, and only target cells (CD7+) clearance rate was significantly higher in CR group. For all 24 cytokines measured in this study showed no significant differences between both groups. Conclusions Base on our data, IL-4, IL-6, IL-8, IL-10, IL-15, IL-22, IFN-γ, sCD25, MCP-1, and Granzyme B were correlated to severity of CRS after CD7 CAR-T therapy. Those 10 cytokines showed positive correlation to the level of CRS, and reached peak time earlier than that of CAR-T expansion, which means all these 10 cytokines could be used as indicators to predict occurrence and severity of CRS. Concurrence time of peak expansion of CD7 CAR-T cells, and amplification of CD8+TEM cells were significantly related to CRS. For all the patients who reached complete remission or CRi, CD7+ clearance rates were higher with statistical significance. Our results proved potential indicators for CRS prediction and prognosis.

T-Charge™ Manufacturing of the Anti-BCMA CAR-T, Durcabtagene Autoleucel (PHE885), Promotes Expansion and Persistence of CAR-T Cells with High TCR Repertoire Diversity

BCMA targeted CAR-T cells are an effective therapy for patients with relapsed or refractory multiple myeloma (r/r MM). However, autologous CAR-T cell products are highly heterogeneous and the functional roles of various T cell populations within these products have not been established. Stem-like memory T cells (Tscm) are a rare T cell subset which maintain high capacity for self-renewal and multipotency. Previously, we demonstrated that the T-Charge TM platform, a novel rapid manufacturing process that reduces manufacturing time to &amp;lt;2 days, preserves less differentiated CAR-T cells which exhibit potent anti-tumor activity and robust expansion in preclinical models (Dexiu Bu, ASH 2021). We conducted a phase 1 clinical trial in r/r MM (NCT04318327) of durcabtagene autoleucel (PHE885), a fully human product manufactured using the T-Charge platform. Here we present a detailed analysis of CAR-T cell products and subsequent expansion of CAR-T cells in 32 patients enrolled in this clinical trial at the Dana-Farber Cancer Institute. Apheresis products (APH), final products (FP) and post-infusion peripheral blood mononuclear cells (PBMC) were characterized using flow cytometry, mass cytometry (CyTOF) and TCR sequencing. We previously reported a 98% overall response rate (ORR) across all dose levels (2.5-20x10 6 CAR-T cells) and 100% ORR at doses &amp;gt;5x10 6 cell dose (Sperling, ASCO 2023). CAR-T cells expanded rapidly after infusion reaching median peak levels of 3,118 cells/ul (range 373 to 17,865) with a median 87.4% (range, 46.9-97.8) of CD3+ T cells expressing the CAR at a median of 14 days (range 10 to 27) after infusion. CAR-T cells persisted at high levels with transgene detectable by qPCR in 67% of patients at 6 months. Among 28 evaluable patients, 13 (43%) had &amp;gt;20% CAR positive T cells detectable by flow cytometry at 3 months. Phenotypic analysis of APH and FP samples showed that less-differentiated T cell subsets, including Tscm and central memory T cells were maintained in FP. CyTOF evaluation of functional markers revealed high expression of proliferation and activation markers in Tscm in FP and subsequently in CAR-T cells at the time of peak expansion in vivo. Subsequently, more differentiated CAR-T cells increased, accompanied by a decline in activation markers, while no significant changes were observed in inhibitory receptors. The proportion of Tscm in the FP positively correlated with early in vivo CAR-T cell expansion. TCR repertoire diversity and TCR clone tracking were used to characterize product manufacturing and CAR-T cells in peripheral blood after infusion. We sorted naïve/Tscm CD4 T cells, naïve/Tscm CD8 T cells, memory CD4 T cells, and memory CD8 T cells from APH and FP, and isolated CAR-positive CD4 T cells, CAR-positive CD8 T cells, CAR-negative CD4 cells, and CAR-negative CD8 T cells from post-infusion PBMC by fluorescence-activated cell sorting and ran TCR sequence from the extracted gDNA from each T cell subpopulation. Measurement of TCR diversity post-infusion revealed higher TCR repertoire diversity in CAR-T cells than in non-CAR-T cells. Notably, post-infusion CAR-T cells shared significantly more TCR clonotypes with T SCM than with memory T cells in the FP, suggesting that the highly heterogeneous post-infusion CAR-T clones were preferentially derived from T SCM clones in the FP. In three evaluable patients with long-term persistence, a highly diverse TCR repertoire in CAR T cells was maintained 1 year after treatment. Our findings demonstrate that the T-Charge™ manufacturing platform successfully maintains highly heterogeneous transduced Tscm clones with self-renewal potential in durcabtagene autoleucel products. Maintenance of Tscm in manufactured products contributes to robust CAR-T expansion and long-term persistence of CAR-T cells with a highly diverse TCR repertoire after infusion.