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Chimeric Antigen Receptor (CAR)-T cells have emerged as a promising immune effector cell-based therapy. With promising results and approval for the treatment of hematological malignancies, we discuss the scope of this novel therapeutic modality in systemic autoimmune diseases and immune-mediated inflammatory disorders refractory to conventional and biological disease-modifying agents.

Background: There is a paucity of data regarding the optimum timing of PCI in relation to TAVR., Objective: We compared the major adverse cardiovascular and cerebrovascular events (MACCE) rates among patients who underwent percutaneous coronary intervention (PCI) before transcatheter aortic valve replacement (TAVR) with those who received PCI with/after TAVR., Methods: In this multicenter study, we pooled all consecutive patients who underwent TAVR at three high volume centers., Results: Among 3,982 patients who underwent TAVR, 327 (8%) patients underwent PCI within 1 year before TAVR, 38 (1%) had PCI the same day as TAVR and 15 (0.5%) had PCI within 2 months after TAVR. Overall, among patients who received both PCI and TAVR (n = 380), history of previous CABG (HR:0.501; p = .001), higher BMI at TAVR (HR:0.970; p = .038), and statin therapy after TAVR (HR:0.660, p = .037) were independently associated with lower MACCE while warfarin therapy after TAVR was associated with a higher risk of MACCE (HR:1.779, p = .017). Patients who received PCI within 1 year before TAVR had similar baseline demographics, STS scores, clinical risk factors when compared to patients receiving PCI with/after TAVR. Both groups were similar in PCI (Syntax Score, ACC/AHA lesion class) and TAVR (valve types, access) related variables. There were no significant differences in terms of MACCE (log rank p = .550), all-cause mortality (log rank p = .433), strokes (log rank p = .153), and repeat PCI (log rank p = .054) in patients who underwent PCI with/after TAVR when compared to patients who received PCI before TAVR., Conclusion: Among patients who underwent both PCI and TAVR, history of CABG, higher BMI, and statin therapy had lower, while those discharged on warfarin, had higher adverse event rates. Adverse events rates were similar regardless of timing of PCI., (© 2020 Wiley Periodicals LLC.)

Purpose: To measure the inter- and intraobserver variability among operators of varying expertise in conducting CT-derived fractional flow reserve (CT FFR) measurements on-site by using structural and fluid analysis and to evaluate differences in reproducibility between two different training methods for end users., Materials and Methods: This retrospective analysis of the prospectively enrolled cohort included 22 symptomatic patients who underwent both 320-detector row coronary CT angiography and catheter-derived fractional flow reserve (FFR) within 90 days. Thirteen operators of varying expertise were assigned to one of two training arms: arm 1, on-site training by a specialist in CT FFR technology; arm 2, self-training through use of written materials. After the training, all 13 operators reviewed the CT data and measured CT FFR in 24 vessels in 22 patients. Inter- and intraoperator variability and agreements between CT FFR and catheter-derived FFR measurements were evaluated., Results: The overall intraclass correlation coefficient (ICC) among operators was 0.71 (95% confidence interval: 0.58, 0.83) with a mean absolute difference (± standard deviation) of 0.027 ± 0.022. The operators in arm 2 showed greater interoperator differences than those in arm 1 (0.031 ± 0.024 vs 0.023 ± 0.018; P = .024). Among operators who recalculated CT FFR, the mean CT FFR value did not significantly differ between the first and second calculations (ICC, 0.66; 95% confidence interval: 0.46, 0.87), with the medical specialists producing the lowest intraoperator variability (0.053 ± 0.060). The overall correlation coefficient between CT FFR and catheter FFR was r = 0.61, with a mean absolute difference of 0.096 ± 0.089., Conclusion: Good reproducibility of CT FFR values calculated on-site on the basis of structural and fluid analysis was observed among operators of varying expertise. Face-to-face training sessions may cause less variability.© RSNA, 2019 Supplemental material is available for this article., Competing Interests: Disclosures of Conflicts of Interest: K.K.K. disclosed no relevant relationships. E.A. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: employed by Canon Medical Systems USA. Other relationships: disclosed no relevant relationships. K.N.S. disclosed no relevant relationships. V.I. disclosed no relevant relationships. M.F.W. Activities related to the present article: institution receives grant from Jacobs Institute. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. N.A. disclosed no relevant relationships. A.B. Activities related to the present article: institution receives grant from Jacobs Institute. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. S.B.K. disclosed no relevant relationships. S.K. Activities related to the present article: institution receives grant from Jacobs Institute. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. S.M. disclosed no relevant relationships. C.M. Activities related to the present article: author did not receive payment or services from a third party for any aspect of the submitted work; author is uncertain if his institution received payment or services from a third party for any aspect of the submitted work (defers to lead author). Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. K.P. disclosed no relevant relationships. T.R. Activities related to the present article: author received payment from the University of Buffalo for participation in review activities. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. A.C.S. disclosed no relevant relationships. M.M.S. Activities related to the present article: institution receives grant from Jacobs Institute. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. S.W. Activities related to the present article: author paid by Toshiba for participating in the data collection of this study. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. S.F. disclosed no relevant relationships. U.C.S. Activities related to the present article: author received consulting fee from Jacobs Neurological Research Institute for interpretation of CT FFT and was fully blinded and not influenced by any means regarding the outcome. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. F.J.R. Activities related to the present article: institution received grant from Canon Medical Systems. Activities not related to the present article: medical director of Imagia (there is no overlap between this work and any company activity). Other relationships: disclosed no relevant relationships. C.N.I. Activities related to the present article: University of Buffalo received grant from Canon Medical Systems; institution receives travel funds for graduate and undergraduates for international conferences. Activities not related to the present article: author paid consultant fee for studies on vascular device evaluation from Jacobs Institute; institution receives NIH grants, Cumming Foundation grant, Canon Medical Systems grant, author paid for lecture on 3D printing advances from Canon Medical Systems; paid for patent for x-ray system design (University of Buffalo); University of Buffalo gives travel grants to conferences. Other relationships: disclosed no relevant relationships., (2019 by the Radiological Society of North America, Inc.)

Background: Aortic stenosis (AS) is a prevalent disease in the elderly population and has been a public health concern for decades. YouTube is currently being used for obtaining healthcare related information. We evaluated the quality of information about AS on YouTube for patient education., Methods: YouTube was queried for the search phrases "aortic valve stenosis", "aortic valve replacement", "transcatheter aortic valve replacement" and "TAVR". Videos were assessed for their reliability and content with two five-point scales. They were categorized into groups according to usefulness and uploader source. All videos were assessed for audience interaction. Videos were viewed and analyzed by 2 independent investigators. Conflicts were resolved by a third investigator., Results: Search phrases yielded 69,300 videos, among which, 120 videos were evaluated and 85 videos were included in the final analysis. Of the 85 videos, only 45 videos (53%) were found to be useful while 40 videos (47%) were found to be non-useful. The majority (98%) of the useful videos were uploaded by professional sources. Overall, videos uploaded by non-professional sources had higher number of views (23,553 vs. 11,110, P≤0.001) despite of being less useful (14% vs. 67%, P<0.001) when compared to videos uploaded by professional sources., Conclusions: There is a potential to increase public awareness about aortic valve stenosis and the available treatment options by utilizing YouTube. Professional societies are encouraged to provide more useful material that can deliver comprehensive and reliable information in an entertaining and intuitive manner to the public., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objective: Neutrophil-to-lymphocyte ratio (NLR) has prognostic value in acute coronary syndromes. We investigated its utility for predicting heart failure (HF) admissions and major adverse cardiac outcomes in patients undergoing transcatheter aortic valve replacement (TAVR)., Methods: Data on clinical, laboratory, procedural, HF admissions, and major adverse cardiac events (MACEs) (all-cause mortality, recurrence of myocardial infarction requiring intervention, stroke) for 298 consecutive patients who underwent TAVR between 2012 and 2016 in our tertiary center were collected., Results: Analysis included 298 patients. The mean age was 83 ± 8 years, 51% were males, and 95% were Caucasians. The median Society of Thoracic Surgeons risk score was 9 (interquartile range: 6.3-11.8). Receiver-operating curve analysis identified a cutoff value of NLR of 4.0 for MACE after TAVR and sensitivity of 68% and specificity of 68% {area under the curve [AUC] = 0.65 [95% confidence interval (CI): 0.51-0.79], p = 0.03}. An NLR of 4.0 for HF hospitalizations after TAVR and sensitivity of 60% and specificity of 57% [AUC = 0.61 (95% CI: 0.53-0.69), p = 0.01]. NLR ≥4.0 before TAVR significantly predicted MACE after TAVR (68.4% vs. 31.6%, p = 0.02) and HF hospitalizations (58.3% vs. 41.7%, p = 0.03). NLR with TAVR risk score increased the predictive value for MACE after TAVR from AUC = 0.61 (95% CI: 0.50-0.72, p = 0.06) to AUC = 0.69 (95% CI: 0.57-0.80, p = 0.007)., Conclusion: NLR predicts all-cause mortality, MACE, and HF hospitalization 1 year after TAVR. NLR with TAVR risk score improved predictability for MACE. Further studies for prognostication using NLR are warranted., (Copyright © 2018 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Background: Permanent pacemaker implantation is the most common complication after Transcatheter aortic valve replacement (TAVR) and is associated with worse outcomes and mortality. However, its impact on quality-of-life (QoL) outcomes remains unknown., Methods: We included 383 consecutive patients undergoing TAVR from January 2012 to 2016 who completed a baseline Kansas City Cardiomyopathy Questionnaire (KCCQ-12) health survey. The clinical, laboratory, angiographic, QoL, mortality, and occurrence of poor outcomes (KCCQ-12 score < 45 or KCCQ decrease of ≥10 points) were obtained., Results: The mean age was 83 ± 8 years, 51% were men, and majority were Caucasians (n = 364, 95%). Permanent pacemaker (PPM) was implanted in 11.5% of patients post-TAVR. PPM patients were more likely to have prior conduction disease including RBBB (25% vs 12%, P = .02) and PQ interval >250 ms (11% vs 5%, P = .07). One-month median KCCQ-12 scores were significantly lower among PPM patients (84.7 vs 68.8, P = .04), but did not differ significantly at 1-year (86.5 vs 90.6, P = .5) post-TAVR. Occurrence of poor outcomes did not differ significantly among those with or without PPM at 1 month (11% vs 7%, P = .39) and 1 year (13% vs 9%, P = .45), respectively. However, patients with poor QoL outcomes at 1 month post-TAVR also had significantly worse mortality during follow-up in unadjusted (31.3% vs 4.5%, P < .001) and adjusted (HR = 5.30, 95% [CI: 1.85-15.22, P = .002])analyses, respectively., Conclusion: Permanent pacemaker implantation is associated with short-term reduction in QoL without long-term implications post-TAVR. Patients with poor QoL post-TAVR also have significantly higher mortality.

Introduction: Microvolt T-wave alternans (MTWA) analysis can identify patients at low risk of sudden cardiac death who might not benefit from an implantable cardioverter-defibrillator (ICD). Current spectral methodology for performing MTWA analysis may "miss" part of the T-wave in patients with QT prolongation. The value of T-wave window adjustment in patients with structural heart disease has not been studied., Methods: We assembled MTWA data from 5 prior prospective studies including 170 patients with reduced left ventricular ejection fraction, adjusted the T-wave window to include the entire T-wave, and reanalyzed MTWA., Results: Of 170 patients, 43% required T-wave window adjustment. Only 3 of 170 patients (1.8%) had a clinically significant change in MTWA results., Conclusions: In 98.2% of patients, T-wave window adjustment did not improve the accuracy of MTWA analysis. Spectral MTWA as currently implemented remains effective for identifying patients with structural heart disease unlikely to benefit from ICD therapy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: Worldwide, more than 247 billion e-mails are sent each day. Little empiric evidence is available to guide how e-mail presentation style, tone, and content affect e-mail recipients and whether these factors impact opinions about the sender and the rapidity of response. In a study of physicians in training assessing a series of 100 e-mail examples, we examined the following: (1) formatting characteristics most and least endorsed, (2) impression of the sender based on the e-mail itself, and (3) factors associated with the decision to respond. We reasoned that our study would provide empiric data to support recommendations for e-mail etiquette, focusing specifically on doctors in training., Design: Cross-sectional survey study., Setting: Division of Orthopaedic Surgery at McMaster University, Hamilton, Ontario, Canada., Participants: After each e-mail, the participating surgical residents completed a series of questions focusing on their impression of the e-mail appearance, their perception of the sender, and their motivation to respond to the e-mail., Results: Thirty-two residents participated in this study. The responses indicate that the key negatively endorsed features of the e-mails included the use of colored backgrounds (84%), difficult-to-read font (83%), lack of a subject header (55%), opening salutations without recipient names (50%), or no salutation at all (42%). The senders of negatively endorsed e-mails were perceived by participants as inefficient (p = 0.03), unprofessional (p < 0.001), and irritating (p = 0.007). E-mails with overall positive endorsements were significantly more likely to have the participants perceive the e-mail senders as professional (p < 0.001), pleasant (p = 0.048), and kind (p = 0.059). The participants were 2.6-fold more likely to respond immediately when they perceived e-mails as favorable compared with disliking them (42% vs 16% of responses, respectively, p < 0.001)., Conclusion: The e-mails perceived as being disliked overall are likely to result in a negative perception of the sender and delays in response time., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: National meetings such as those of the American Academy of Orthopaedic Surgeons (AAOS) and the Canadian Orthopaedic Association (COA) are invaluable in the dissemination of new research findings. Given the limits of meeting agendas, investigators who present the same paper at multiple meetings prevent other presentations on potentially important original research. To determine the incidence of duplicate presentation of research between recent COA and AAOS meetings and between national meetings (AAOS and subspecialty), we conducted an observational study., Methods: We hand-searched all podium papers and posters from the 2001 COA annual meeting for duplicate presentation at the 2001 and 2002 AAOS annual meetings and subspecialty meetings held in the USA. We evaluated summary data abstracted from the duplicate presentations for consistency., Results: Of 148 presentations at the 2001 COA meeting, 29 presentations (paper and poster) were duplicated at the 2001 or 2002 AAOS meeting: effectively 1 paper in 5 (19.5%). Canadian investigators were significantly more likely to present the same paper at both meetings than Americans (79% v. 13%, respectively; p < 0.01). Those who presented papers at COA altered their AAOS presentations in a variety of ways: by changing the wording in the title of their paper (24% of the time), adding or removing authors (38%), changing authorship order (34%) and changing the sample size (31%). Duplicate presentation rates between AAOS and other orthopedic subspecialty meetings averaged 11.4% (range 3.4%-26.4%)., Conclusions: We identified a 20% duplicate presentation rate between the COA and AAOS annual meetings, and an 11% rate between the AAOS and subspecialty meetings. Stricter enforcement of guidelines and improved dissemination of research findings at both national meetings may limit this practice.