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Objective/Background: Chimeric antigen receptor (CAR) T-cell is an effective therapy in relapsed/refractory large B-cell lymphomas that, due to its unique toxicities, often requires escalation of care to the intensive care unit (ICU) setting. C-reactive protein (CRP) and ferritin are serum inflammatory markers associated with onset and persistence of CAR T-cell-related toxicity. Methods: We retrospectively analyzed 34 patients treated with axicabtagene ciloleucel (axi- cel) who were divided into two groups: patients requiring admission to the ICU during initial hospitalization (n = 13, 38%) and those who did not (n = 21, 62%). Primary objective was to examine possible relationships between serum ferritin and/or CRP levels with the need for, and length of, ICU stay between these groups. Results: All 13 patients admitted to the ICU developed cytokine release syndrome (CRS) and 11 of them also developed neurotoxicity (NT). Of the 21 patients in the non-ICU group, 18 developed CRS and 5 patients developed NT. Grade of CRS and NT were higher in ICU versus non-ICU patients (p = .03 and .001, respectively). There was no correlation between CRP levels at time of ICU admission and length of ICU stay (correlation of 0.41, p = .17). Yet, there was an association between serum ferritin levels and length of ICU stay (R 2 = 0.73) which did not reach statistical significance (correlation of 0.21, p = .49). Conclusion: Notwithstanding the limitations of the small sample size, our study suggests that an elevated ferritin level at the time of escalation of medical care may be possibly indicative of anticipated prolonged ICU hospitalization in patients treated with axi-cel. A large multicenter study is certainly needed to confirm this observation.

The aim of this article is to present and discuss: 1) types of lumbar traction; 2) effects of lumbar traction; 3) indications and contraindications for lumbar traction; 4) effective lumbar traction techniques. There is a review of important points that have been presented in earlier literature, as well as the introduction of new ideas and concepts. A portion of this article deals with the rationale-of using lumbar traction for the treatment of herniated disc and other lumbar spinal nerve root syndromes. There is considerable discussion of poundages necessary to achieve therapeutic results. Detailed description of positioning is presented. The importance of the use of proper equipment for mechanical lumbar traction is stressed. That lumbar traction can be a beneficial treatment for certain musculoskeletal disorders is stressed, but that effective treatment is not as easy and simple to administer as it may seem. J Orthop Sports Phys Ther 1979;1(1):36-45.

Average volume-assured pressure support (AVAPS) is a comparatively newer modality of non-invasive ventilation that incorporates the properties of both volume and pressure-control ventilation. Though its benefits were well documented in chronic respiratory failure, studies illustrating its usage in acute respiratory failure are still insubstantial. Herein, we aim to showcase the utility of AVAPS in the management of acute on chronic hypercapnic respiratory failure.CASE PRESENTATION: An 80-year-old female with a body mass index (BMI) of 37 kg/m2 and chronic opiate use presented to the Emergency Department (ED) following a two-day history of increasing shortness of breath and confusion. Her medical history was notable for hypersensitivity pneumonitis secondary to bird exposure, former smoker, paroxysmal atrial fibrillation, and recent acute pericarditis for which she is taking aspirin and colchicine. An arterial blood gas (ABG) showed a pH of 7.14, PaCO2 of 124 mmHg (FiO2 28%), PaO2 of 94 mmHg, and bicarbonate of 41 mmol/L. A chest x-ray showed increased bilateral interstitial infiltrates. The patient received IV methylprednisolone and was placed on Spontaneous/Timed mode Bilevel positive airway pressure (BiPAP S/T) with an Inspiratory positive airway pressure (IPAP) of 10 mmHg, Expiratory positive airway pressure (EPAP) of 5 mmHg, and a respiratory rate of 12/min. At these set pressures, her inspired tidal volumes were around 400ml. The patient continued to remain confused (GCS 12/15) and thus, she was switched to average volume-assured pressure support (AVAPS) with a target tidal volume of 500ml. With this modality, she displayed rapid improvement in her symptoms and an ABG drawn eight hours after initiation revealed a pH of 7.34, PaO2 of 66 mmHg, PaO2 of 135 mmHg (FiO2 50%), and bicarbonate of 34 mmol/L. The patient was discharged home on the 5th day after admission. DISCUSSION: AVAPS is an intelligent modality of non-invasive pressure support that gives us the option to set a maximum and a minimum IPAP, in place of one fixed IPAP setting, along with a target tidal volume. The ventilator automatically adjusts the inspiratory pressure within the set range to ensure the delivery of pre-set tidal volume. Patient-ventilator dyssynchronization is prevented and previous studies have reported better patient comfort and satisfaction with AVAPS, thereby, improving patient compliance to the treatment. AVAPS was shown to be superior to BiPAP S/T and associated with a rapid improvement of ABG values and GCS score in patients with acute hypercapnic respiratory failure complicated with hypercapnic encephalopathy (GCS <10/15). CONCLUSIONS: Our case highlights the valuable utility of AVAPS and how, in certain clinical situations, it may be a preferred first-line modality over standard BiPAP S/T for the treatment of acute hypercapnic respiratory failure.

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