What precautions will a patient need to take once they are home?

What precautions will a patient have to take once they're home? Infection is the key, and I think this is just so important because when we engineer the CAR T cell to wind onto the surface of the cancer cell, oftentimes a similar target is also expressed on the normal plasma cells. So there are unintended targets that got wiped off as well. So we classically see that patient's level of normal antibody goes down a lot. There are some strategies to infuse what we call immunoglobulin, sort of a general antibody molecule just so that you have a little bit more. How I tell my patients is it's like money in your bank. You want to have enough because when you don't have enough, you're actually at risk for a variety of things. There are also considerations to use antiviral agents or antibacterial agents, particularly when the neutrophil levels continue to be low. Ultimately, the general common sense of also keeping yourself safe, social distancing during the critical time, such as where we are now with COVID, but also think about vaccination down the road, the flu vaccine, COVID vaccine is important, but also talk to your doctors about when is the best time to do it because immediately post CAR T cell therapy probably isn't the right time because your immune system is too suppressed to recognize some of these vaccines. CAR T is very suppressive to the body's immune system and patients' risk of developing serious fungal pneumonias, viral infections are quite substantially heightened. They also have a significant risk of developing bacterial infection. So a lot of the focus is preventing late infections following the 30 day recovery phase. Patients really need to be quite meticulous regarding their exposures to other individuals. And particularly in the COVID era, it becomes a real problem. Will patients have to follow a neutropenic diet like autologous stem cell transplant? I generally try to be on the cautious side. So I think when the patient's neutrophils are still low, it probably is reasonable to do so. Now, the difference between the CAR T and the autologous transplant with high-dose morpholin, though, is that patients who go through CAR T usually don't have as much mucosal breakdown. When we think about neutropenic diet, we think about germs that snake into the body when the gut lining is impaired. We don't see the gut lining being sloughed off with the CAR T, so perhaps the neutropenic diet isn't as critical. But just whenever I say that, there's always someone coming in with a diarrhea, so I usually just try to be on the safe side. It's customary to do that, but it's really not very well proven. I mean, there's naturally occurring bacteria on the surface, for example, of fruits that can't be peeled, like berries and strawberries, where things that have a peel, like oranges and bananas, they're sterile inside. Grapes have bacteria on the surface. It's not really well known how many of those bacteria on those fruits and vegetables, celery and the like, carry harmful bacteria, but I think generally the custom has been to recommend avoidance of vegetables that really aren't sterile, meaning they don't have a peel. As long as they don't have neurotoxicity, and I think that's something to mention because it can still happen after patients leave the hospital. It's rare, but when it happens, it's unique to that patient, and I think the ability to really navigate the vehicle really depends a whole lot on what's going on in that unique patient. I usually will say it is possible to gain your independence and your life back, but I would definitely encourage discussion with a treating physician. Neurocognitive decline or neuropathy. Patients are at risk for altered or decreased consciousness or coordination in the eight weeks following carvicti infusion. Advise patients to refrain from driving and engaging in hazardous occupations or activities, such as operating heavy or potentially dangerous machinery during this initial period, and in the event of new onset of any neurologic toxicities. Going out into the public is so important for the emotional health, but I also think that if you're going to do something like that, do it with some caution. Definitely don't go into big crowded space without protecting yourself, and knowing who you come into contact with is key. If it's your own family members, if it's someone who you know have already been vaccinated for COVID particularly, that's better comparing to going out into the unknown. So it depends on some of the numbers when they go home. Most patients have very specific immune parameters that are measured at the time of their discharge. And so the recommendations are going to be quite varied depending on the severity of their immune recovery or lack thereof.