High-dimensional analyses reveal a distinct role of T-cell subsets in the immune microenvironment of gastric cancer.

OBJECTIVES: To facilitate disease prognosis and improve precise immunotherapy of gastric cancer (GC) patients, a comprehensive study integrating immune cellular and molecular analyses on tumor tissues and peripheral blood was performed. METHODS: The association of GC patients' outcomes and the immune context of their tumors was explored using multiplex immunohistochemistry (mIHC) and transcriptome profiling. Potential immune dysfunction mechanism/s in the tumors on the systemic level was further examined using mass cytometry (CyTOF) in complementary peripheral blood from selected patients. GC cohorts with mIHC and gene expression profiling data were also used as validation cohorts. RESULTS: Increased CD4+FOXP3+ T-cell density in the GC tumor correlated with prolonged survival. Interestingly, CD4+FOXP3+ T cells had a close interaction with CD8+ T cells rather than tumor cells. High densities of CD4+FOXP3+ T cells and CD8+ T cells (High-High) independently predicted prolonged patient survival. Furthermore, the interferon-gamma (IFN-γ) gene signature and PDL1 expression were up-regulated in this group. Importantly, a subgroup of genomically stable (GS) tumors and tumors with chromosomal instability (CIN) within this High-High group also had excellent survival. The High-High GS/CIN tumors were coupled with increased frequencies of Tbet+CD4+ T cells and central memory CD4+ T cells in the peripheral blood. CONCLUSION: These novel findings identify the combination of CD8+ T cells and FOXP3+CD4+ T cells as a significant prognostic marker for GC patients, which also could potentially be targeted and applied in the combination therapy with immune checkpoint blockades in precision medicine.

Ultrasonography in the intensive care setting can be used to detect changes in the quality and quantity of muscle and is related to muscle strength and function.

PURPOSE: This study aimed to (1) document patterns of quadriceps muscle wasting in the first 10 days of admission and (2) determine the relationship between muscle ultrasonography and volitional measures. MATERIALS AND METHODS: Twenty-two adults ventilated for more than 48 hours were included. Sequential quadriceps ultrasound images were obtained over the first 10 days and at awakening and intensive care unit (ICU) discharge. Muscle strength and function were assessed at awakening and ICU discharge. RESULTS: A total of 416 images were analyzed. There was a 30% reduction in vastus intermedius (VI) thickness, rectus femoris (RF) thickness, and cross-sectional area within 10 days of admission. Muscle echogenicity scores increased for both RF and VI muscles by +12.7% and +25.5%, respectively (suggesting deterioration in muscle quality). There was a strong association between function and VI thickness (r = 0.82) and echogenicity (r = -0.77). There was a moderate association between function and RF cross-sectional area (r = 0.71). CONCLUSIONS: Muscle wasting occurs rapidly in the ICU setting. Ultrasonography is a useful surrogate measure for identifying future impairment. Vastus intermedius may be an important muscle to monitor in the future because it demonstrated the greatest change in muscle quality and had the strongest relationship to volitional measures.

Minimal important difference of the 6-minute walk distance in lung cancer.

The 6-minute walk distance (6MWD) is one of the most commonly used measures of functional capacity in lung cancer, however, the minimal important difference (MID) has not been established. The aims of this exploratory study are, in lung cancer, to estimate (1) the MID of the 6MWD and (2) relationship between 6MWD, demographic and disease-related factors. Fifty-six participants with stage I-IV lung cancer completed the 6MWD prior to treatment and 10 weeks later. No exercise intervention occurred. Additional measures included European Organization for Research and Treatment of Cancer questionnaire (EORTC-QLQ-C30) and questionnaires assessing function, physical activity and symptoms. MID was calculated using anchor- and distribution-based methods. The mean 6MWD decline in participants classed as deteriorated was 60 m compared with 16 m in participants classed as not-deteriorated (p = 0.01). The receiver operating curve indicated a cut-off value for clinically relevant change to be 42 m (95% confidence interval (CI) 6-75) (area under curve = 0.66, 95% CI 0.51-0.81) or a 9.5% change. Distribution-based methods indicated an MID between 22 m (95% CI 18-26) and 32 m (95% CI 20-42). Higher 6MWD correlated with better function (r = -0.42, p = 0.001), physical activity (r = 0.56, p < 0.005) and dyspnoea (r = -0.44, p = 0.001). The MID for deterioration of the 6MWD in lung cancer is estimated to be between 22 m and 42 m or a change of 9.5%.

A postoperative shoulder exercise program improves function and decreases pain following open thoracotomy: a randomised trial.

QUESTION: Does a postoperative physiotherapy exercise program incorporating shoulder exercises improve shoulder function, pain, range of motion, muscle strength, and health-related quality of life in patients undergoing elective pulmonary resection via open thoracotomy? DESIGN: Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS: 76 patients who underwent pulmonary resection via open thoracotomy. INTERVENTION: All participants received standard medical and nursing care involving a clinical pathway. The experimental group also received physiotherapy interventions that included daily supervised, progressive exercises until discharge and a postoperative exercise booklet on discharge. OUTCOME MEASURES: Preoperatively and up to 3 months postoperatively pain was measured with a numerical rating scale, shoulder function with the Shoulder Pain and Disability Index, and quality of life with the Short Form-36. Shoulder range of motion and muscle strength were measured in a subgroup. RESULTS: The experimental group had 1.3 units (95% CI 0.3 to 2.2) less shoulder pain (scored /10) and 2.2 units (95% CI 0.2 to 4.3) less total pain (scored /30) at discharge, and 7.6% (95% CI 1.7 to 13.6) better function at 3 months. The Short Form-36 physical component score was 4.8 points (95% CI -0.3 to 10.0) better for the experimental group than the control group at 3 months. Differences between groups in all range of motion and strength measures were small and statistically non-significant. CONCLUSION: A physiotherapist-directed postoperative exercise program resulted in significant benefits in pain and shoulder function over usual care for patients following open thoracotomy. TRIAL REGISTRATION: ANZCTRN 12605000201673.

Does physiotherapy reduce the incidence of postoperative pulmonary complications following pulmonary resection via open thoracotomy? A preliminary randomised single-blind clinical trial.

OBJECTIVE: This study investigates whether targeted postoperative respiratory physiotherapy decreased the incidence of postoperative pulmonary complications and length of stay for patients undergoing elective pulmonary resection via open thoracotomy. METHODS: Seventy-six patients participated in a prospective, single-blind, parallel-group, randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis. Treatment group participants received daily respiratory physiotherapy interventions until discharge. Control group participants received standard medical/nursing care involving a clinical pathway. The presence of postoperative pulmonary complications was assessed on a daily basis during hospitalisation using a standardised diagnostic tool. Length of stay was recorded. RESULTS: Postoperative pulmonary complications developed in two participants (4.8%) in the treatment group and in one participant (2.9%) in the control group; the difference (treatment minus control) was 1.8% (95% confidence interval (CI) -10.6% to 13.1%) (p=1.00). No significant difference was found between groups for length of stay (treatment group, median 6.0 days; control group 6.0 days) (p=0.87). A preoperative forced expiratory volume in 1s of 1.5l or less (p=0.005) and a history of chronic obstructive pulmonary disease (p=0.008) were associated with a greater number of criteria for a postoperative pulmonary complication being met. CONCLUSIONS: In this patient population, given the low incidence of postoperative pulmonary complications, targeted respiratory physiotherapy may not be required in addition to standard care involving a clinical pathway following pulmonary resection via open thoracotomy. These results should be extrapolated with caution to those patients undergoing pulmonary resection with poor preoperative lung function.

Comparable patencies of the radial artery and right internal thoracic artery or saphenous vein beyond 5 years: results from the Radial Artery Patency and Clinical Outcomes trial.

OBJECTIVE: To investigate the optimum conduit for coronary targets other than the left anterior descending artery, we evaluated long-term patencies and clinical outcomes of the radial artery, right internal thoracic artery, and saphenous vein through the Radial Artery Patency and Clinical Outcomes trial. METHODS: As part of a 10-year prospective, randomized, single-center trial, patients undergoing primary coronary surgery were allocated to the radial artery (n = 198) or free right internal thoracic artery (n = 196) if aged less than 70 years (group 1), or radial artery (n = 113) or saphenous vein (n = 112) if aged at least 70 years (group 2). All patients received a left internal thoracic artery to the left anterior descending, and the randomized conduit was used to graft the second largest target. Protocol-directed angiography has been performed at randomly assigned intervals, weighted toward the end of the study period. Grafts are defined as failed if there was occlusion, string sign, or greater than 80% stenosis, independently reported by 3 assessors. Analysis is by intention to treat. RESULTS: At mean follow up of 5.5 years, protocol angiography has been performed in groups 1 and 2 in 237 and 113 patients, respectively. There are no significant differences within each group in preoperative comorbidity, age, or urgency. Patencies were similar for either of the 2 conduits in each group (log rank analysis, P = .06 and P = .54, respectively). The differences in estimated 5-year patencies were 6.6% (radial minus right internal thoracic artery) in group 1 and 2.9% (radial minus saphenous vein graft) in group 2. CONCLUSION: At mean 5-year angiography in largely asymptomatic patients, the selection of arterial or venous conduit for the second graft has not significantly affected patency. This finding offers surgeons, for now, enhanced flexibility in planning revascularization.

Leukemia inhibitory factor signaling modulates both central nervous system demyelination and myelin repair.

Leukemia inhibitory factor (LIF) receptor signaling limits the severity of inflammatory demyelination in experimental autoimmune encephalomyelitis, a T-cell dependent animal model of multiple sclerosis (MS) [Butzkueven et al. (2002) Nat Med 8:613-619]. To identify whether LIF exerts direct effects within the central nervous system to limit demyelination, we have studied the influence of LIF upon the phenotype of mice challenged with cuprizone, a copper chelator, which produces a toxic oligodendrocytopathy. We find that exogenously administered LIF limits cuprizone-induced demyelination. Knockout mice deficient in LIF exhibit both potentiated demyelination and oligodendrocyte loss after cuprizone challenge, an effect that is ameliorated by exogenous LIF, arguing for a direct beneficial effect of endogenous LIF receptor signaling. Numbers of oligodendrocyte progenitor cells in cuprizone-challenged mice are not influenced by either exogenous LIF or LIF deficiency, arguing for effects directed to the differentiated oligodendrocyte. Studies on the influence of LIF upon remyelination after cuprizone challenge fail to reveal any significant effect of exogenous LIF. The LIF-knockout mice do, however, display impaired remyelination, although oligodendrocyte replenishment, previously identified to occur from the progenitor pool, is not significantly compromised. Thus endogenous LIF receptor signaling is not only protective of oligodendrocytes but can also enhance remyelination, and exogenous LIF has therapeutic potential in limiting the consequences of oligodendrocyte damage.

Accounting for dependence in similarity data from DNA fingerprinting.

Differentiating strains of a pathogen is often central to investigating its epidemiological aspects. The genetic similarity of a group of strains can be assessed by calculating a matrix of dissimilarities from their DNA fingerprinting profiles. The mean dissimilarity for each strain across other strains within the group is then used as an observation in a statistical analysis. These observations are not independent of each other, and so standard analysis techniques such as the t-test are inappropriate, because they underestimate the variance of the group means, and hence overstate the statistical significance of any differences. By examining the correlation between elements of the dissimilarity matrix, it is shown that the variance is underestimated by a factor of between about 2 and 4. Permutation tests are proposed as a way of addressing the problem of dependence, and are applied to a study of fluconazole resistance in Candida albicans.

A simple method for inference on an overall effect in meta-analysis.

The random effects approach in meta-analysis due to DerSimonian and Laird is well established and used pervasively. It has been established by Brockwell and Gordon that this method, when used for confidence intervals, leads to coverage probabilities lower than the nominal value. A number of alternatives have been proposed, but these either have the defect of iterative and complicated calculation, or deficient coverage. In this paper we propose a new approach, which is simple to use, and has coverage probabilities better than the alternatives, based on extensive simulation. We call this approach the 'quantile approximation' method.

An outbreak of Legionnaires' disease at the Melbourne Aquarium, April 2000: investigation and case-control studies.

OBJECTIVE: To investigate the source and risk factors associated with Australia's largest outbreak of Legionnaires' disease. DESIGN AND SETTING: Epidemiological and environmental investigation of cases of Legionnaires' disease associated with visits to the Melbourne Aquarium; two case-control studies to confirm the outbreak source and to investigate risk factors for infection, respectively. PARTICIPANTS: Patients with confirmed Legionnaires' disease who visited the Melbourne Aquarium between 11 and 27 April 2000 were compared (i) with control participants from the community, and (ii) with control participants selected from other visitors to the Aquarium during this period. MAIN OUTCOME MEASURES: Risk factors for acquiring Legionnaires' disease. RESULTS: There were 125 confirmed cases of Legionnaires' disease caused by Legionella pneumophila serogroup 1 associated with the Aquarium; 76% of patients were hospitalised, and four (3.2%) died. The Aquarium cooling towers were contaminated with this organism. Visiting the Aquarium was significantly associated with disease (odds ratio [OR], 207; 95% CI, 73-630). The case-control study indicated that current smoking was a dose-dependent risk (multivariable OR for currently smoking > 70 cigarettes/week, 13.5; 95% CI, 5-36), but chronic illness and duration of exposure at the site were not significant risks. CONCLUSIONS: This study showed an association between poorly disinfected cooling towers at the Aquarium and Legionnaires' disease in visitors, and confirmed current smoking as a critical risk factor. The rapid response, publicity, and widespread urinary antigen testing may have resulted in detection of milder cases and contributed to the relatively low apparent morbidity and mortality rates. The urinary antigen test allows rapid identification of cases and may be changing the severity of illness recognised as Legionnaires' disease and altering who is considered at risk.