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UNLABELLED: Fluorescence-guided surgery is set to play a pivotal role in the intraoperative management of pediatric tumors. Shortwave infrared imaging (SWIR) has advantages over conventional near-infrared I (NIR-I) imaging with reduced tissue scattering and autofluorescence. Here, two NIR-I dyes (IRDye800CW and IR12), with long tails emitting in the SWIR range, were conjugated with a clinical-grade anti-GD2 monoclonal antibody (dinutuximab-beta) to compare NIR-I and SWIR imaging for neuroblastoma surgery. A first-of-its-kind multispectral NIR-I/SWIR fluorescence imaging device was constructed to allow an objective comparison between the two imaging windows. Conjugates were first characterized in vitro. Tissue-mimicking phantoms, imaging specimens of known geometric and material composition, were used to assess the sensitivity and depth penetration of the NIR-I/SWIR device, showing a minimum detectable volume of ∼0.9 mm3 and depth penetration up to 3 mm. In vivo, fluorescence imaging using the NIR-I/SWIR device showed a high tumor-to-background ratio (TBR) for both dyes, with anti-GD2-IR800 being significantly brighter than anti-GD2-IR12. Crucially, the system enabled higher TBR at SWIR wavelengths than at NIR-I wavelengths, verifying SWIR imaging enables high-contrast delineation of tumor margins. This work demonstrates that by combining the high specificity of anti-GD2 antibodies with the availability and translatability of existing NIR-I dyes, along with the advantages of SWIR in terms of depth and tumor signal-to-background ratio, GD2-targeted NIR-I/SWIR-guided surgery could improve the treatment of patients with neuroblastoma, warranting investigation in future clinical trials. SIGNIFICANCE: Multispectral near-infrared I/shortwave infrared fluorescence imaging is a versatile system enabling high tumor-to-background signal for safer and more complete resection of pediatric tumors during surgery. ispartof: Cancer Res vol:83 issue:12 pages:2077-2089 ispartof: location:United States status: published

Early detection of esophageal neoplasia enables curative endoscopic therapy, but the current diagnostic standard of care has low sensitivity because early neoplasia is often inconspicuous with conventional white-light endoscopy. Here, we hypothesized that spectral endoscopy could enhance contrast for neoplasia in surveillance of patients with Barrett's esophagus. A custom spectral endoscope was deployed in a pilot clinical study of 20 patients to capture 715 in vivo tissue spectra matched with gold standard diagnosis from histopathology. Spectral endoscopy was sensitive to changes in neovascularization during the progression of disease; both non-dysplastic and neoplastic Barrett's esophagus showed higher blood volume relative to healthy squamous tissue (P = 0.001 and 0.02, respectively), and vessel radius appeared larger in neoplasia relative to non-dysplastic Barrett's esophagus (P = 0.06). We further developed a deep learning algorithm capable of classifying spectra of neoplasia versus non-dysplastic Barrett's esophagus with high accuracy (84.8% accuracy, 83.7% sensitivity, 85.5% specificity, 78.3% positive predictive value, and 89.4% negative predictive value). Exploiting the newly acquired library of labeled spectra to model custom color filter sets identified a potential 12-fold enhancement in contrast between neoplasia and non-dysplastic Barrett's esophagus using application-specific color filters compared with standard-of-care white-light imaging (perceptible color difference = 32.4 and 2.7, respectively). This work demonstrates the potential of endoscopic spectral imaging to extract vascular properties in Barrett's esophagus, to classify disease stages using deep learning, and to enable high-contrast endoscopy.Significance:The results of this pilot first-in-human clinical trial demonstrate the potential of spectral endoscopy to reveal disease-associated vascular changes and to provide high-contrast delineation of neoplasia in the esophagus.

Supplementary Data from Spectral Endoscopy Enhances Contrast for Neoplasia in Surveillance of Barrett's Esophagus

We report the synthesis of the carbon-14-labeled unnatural nucleoside islatravir, an investigational HIV drug, through a one-pot biocatalytic cascade starting from acetaldehyde-2-14C. Combining enz...

BackgroundPixatimod is a unique activator of the Toll-like Receptor 9 pathway. This phase I trial evaluated safety, efficacy and pharmacodynamics of pixatimod and PD-1 inhibitor nivolumab in immunologically cold cancers.Methods3+3 dose escalation with microsatellite stable metastatic colorectal cancer (MSS mCRC) and metastatic pancreatic ductal adenocarcinoma (mPDAC) expansion cohorts. Participants received pixatimod once weekly as a 1-hour intravenous infusion plus nivolumab every 2 weeks. Objectives included assessment of safety, antitumor activity, pharmacodynamics, and pharmacokinetic profile.ResultsFifty-eight participants started treatment. The maximum tolerated dose of pixatimod was 25 mg in combination with 240 mg nivolumab, which was used in the expansion phases of the study. Twenty-one grade 3–5 treatment-related adverse events were reported in 12 participants (21%); one participant receiving 50 mg pixatimod/nivolumab had a treatment-related grade 5 AE. The grade 3/4 rate in the MSS mCRC cohort (n=33) was 12%. There were no responders in the mPDAC cohort (n=18). In the MSS mCRC cohort, 25 participants were evaluable (initial postbaseline assessment scans >6 weeks); of these, three participants had confirmed partial responses (PR) and eight had stable disease (SD) for at least 9 weeks. Clinical benefit (PR+SD) was associated with lower Pan-Immune-Inflammation Value and plasma IL-6 but increased IP-10 and IP-10/IL-8 ratio. In an MSS mCRC participant with PR as best response, increased infiltration of T cells, dendritic cells, and to a lesser extent NK cells, were evident 5 weeks post-treatment.ConclusionsPixatimod is well tolerated at 25 mg in combination with nivolumab. The efficacy signal and pharmacodynamic changes in MSS mCRC warrants further investigation.Trial registration numberNCT05061017.

Natural killer (NK) cells are a heterogeneous population of innate lymphocytes whose potent anticancer properties make them ideal candidates for cellular therapeutic application. However, our lack of understanding of the role of NK cell diversity in antitumor responses has hindered advances in this area. In this study, we describe a new CD56dim NK cell subset characterized by the lack of expression of DNAX accessory molecule-1 (DNAM-1). Compared with CD56bright and CD56dimDNAM-1pos NK cell subsets, CD56dimDNAM-1neg NK cells displayed reduced motility, poor proliferation, lower production of interferon-γ, and limited killing capacities. Soluble factors secreted by CD56dimDNAM-1neg NK cells impaired CD56dimDNAM-1pos NK cell–mediated killing, indicating a potential inhibitory role for the CD56dimDNAM-1neg NK cell subset. Transcriptome analysis revealed that CD56dimDNAM-1neg NK cells constitute a new mature NK cell subset with a specific gene signature. Upon in vitro cytokine stimulation, CD56dimDNAM-1neg NK cells were found to differentiate from CD56dimDNAM-1pos NK cells. Finally, we report a dysregulation of NK cell subsets in the blood of patients diagnosed with Hodgkin lymphoma and diffuse large B-cell lymphoma, characterized by decreased CD56dimDNAM-1pos/CD56dimDNAM-1neg NK cell ratios and reduced cytotoxic activity of CD56dimDNAM-1pos NK cells. Altogether, our data offer a better understanding of human peripheral blood NK cell populations and have important clinical implications for the design of NK cell–targeting therapies.

Early detection and resection of adenomatous polyps prevents their progression to colorectal cancer (CRC), significantly improving patient outcomes. Polyps are typically identified and removed during white-light colonoscopy. Unfortunately, the rate of interval cancers that arise between CRC screening events remains high, linked to poor visualization of polyps during screening and incomplete polyp removal. Here, we sought to evaluate the potential of a hyperspectral endoscope (HySE) to enhance polyp discrimination for detection and resection. We designed, built and tested a new compact HySE in a proof-of-concept clinical study. We successfully collected spectra from three tissue types in seven patients undergoing routine colonoscopy screening. The acquired spectral data from normal tissue and polyps, both pre- and post- resection, were subjected to quantitative analysis using spectral angle mapping and machine learning, which discriminated the data by tissue type, meriting further investigation of HySE as a clinical tool.

Significance: The early detection of dysplasia in patients with Barrett’s esophagus could improve outcomes by enabling curative intervention; however, dysplasia is often inconspicuous using conventional white-light endoscopy. Aim: We sought to determine whether multispectral imaging (MSI) could be applied in endoscopy to improve detection of dysplasia in the upper gastrointestinal (GI) tract. Approach: We used a commercial fiberscope to relay imaging data from within the upper GI tract to a snapshot MSI camera capable of collecting data from nine spectral bands. The system was deployed in a pilot clinical study of 20 patients (ClinicalTrials.gov NCT03388047) to capture 727 in vivo image cubes matched with gold-standard diagnosis from histopathology. We compared the performance of seven learning-based methods for data classification, including linear discriminant analysis, k-nearest neighbor classification, and a neural network. Results: Validation of our approach using a Macbeth color chart achieved an image-based classification accuracy of 96.5%. Although our patient cohort showed significant intra- and interpatient variance, we were able to resolve disease-specific contributions to the recorded MSI data. In classification, a combined principal component analysis and k-nearest-neighbor approach performed best, achieving accuracies of 95.8%, 90.7%, and 76.1%, respectively, for squamous, non-dysplastic Barrett’s esophagus and neoplasia based on majority decisions per-image. Conclusions: MSI shows promise for disease classification in Barrett’s esophagus and merits further investigation as a tool in high-definition “chip-on-tip” endoscopes.

Plasma Event TRiggering for Alarms (PETRA) is a flexible new system at JET for detecting plasma events to trigger exception handling responses. It provides a platform for all existing and new techniques which involve processing JET real-time data to identify when to change the trajectory of a plasma shot, and reduces the technical cost and risk in demonstrating new techniques. At the same time as providing a protection function to the machine, it still supports additions and modifications to the event detector library during the course of an experimental campaign. It has successfully demonstrated novel techniques, and has computational capacity to continue supporting research into further event detection triggers.

International audience; Key messageThe 19-year monitoring study revealed continuously positive and dynamic responses of tree growth to logging residue loadings. However, the lack of changes in soil nutrients suggested that increased growth might result from enhanced nutrient cycling with no net accumulation in the soil.ContextUnderstanding how logging residue loadings affect soil nutrients and forest growth is critical for designing management strategies for sustaining long-term productivity in forest ecosystems.AimsWe aimed to examine the relationships among logging residue loadings, soil nutrients, and tree growth over a long-term field experiment in lodgepole pine (Pinus contorta Doug. ex Loud.) forests.MethodsWe established a field experiment in 1996 to examine the responses of lodgepole pine growth and soil nutrients to four residue loading treatments in the central interior of British Columbia, Canada. The four treatments were removal of all residues on the forest floor (N, 0 mg ha−1), residues loading similar to whole-tree harvesting (W, 35–45 mg ha−1), residues loading similar to stem-only harvesting (S, 60–70 mg ha−1), and residues loading similar to that found in disease- or insect-killed forests (D, 100–120 mg ha−1).ResultsLogging residue loadings had significantly positive and dynamic effects on diameter and height growths. The logging residue loadings did not significantly change soil nutrients in mineral soil pools in the long run, and there was no difference in tree growth between the treatments S and W over the study period.ConclusionLogging residue loadings significantly improved tree growth. The lack of response of soil nutrients leads to the hypothesis that nutrient fluxes from logging residues might play a more important role in tree growth in lodgepole pine forests. Our results can have important implications for bio-energy production and designing of nature-based practices for sustainable forest productivity.

Advanced optical endoscopic imaging techniques, including hyperspectral and holographic endoscopy, have shown promise in the improved diagnosis of the early stage of cancer. However, clinical applications of these imaging systems are still limited due to unclear diagnostic optical properties. Here, we developed a compact multimodal imaging system that enables hyperspectral imaging, spatial-frequency domain imaging, and 3D profilometric imaging to characterise the optimal optical features for the early detection of lesions. Optical properties of fresh specimens obtained from patients were measured within 30 minutes, and then histopathological assessment of specimens was performed to link extracted optical features to gold-standard diagnosis. With further sample collection and system refinements, this system can be used for high-throughput optical characterisation of fresh tissue specimens, allowing us to determine the optical signatures of early-stage disease.

Hyperspectral imaging techniques measure spatial and spectral information, which enables discrimination between healthy tissue and lesions. Hyperspectral imaging applications in endoscopy for clinical diagnostic applications are still limited due to image distortion challenges that arise when working with a flexible endoscope, for example in the gastrointestinal tract. Here, we developed a hyperspectral endoscopy (HySE) system by exploiting a line-scanning spectrograph to measure spectral information at high spectral resolution and combining it with a CMOS camera that records wide-field images for hyperspectral image reconstruction. Moreover, we developed an image normalisation method using near-infrared light to obtain accurate hyperspectral signals by correcting uneven illumination conditions during clinical endoscopy. Our next step is to apply HySE to patients to identify abnormal features in the gastrointestinal tract in vivo.

OBJECTIVES Out-of-hospital cardiac arrest (OHCA) is rare in infants, with the cause of arrest often unknown upon presentation. Nonaccidental trauma is a potential etiology of OHCA among infants, but its occult presentation makes this etiology challenging to diagnose. In the absence of apparent injuries, identifying the need for trauma team activation is difficult during the initial resuscitation of infants with OHCA. METHODS We performed a retrospective chart review of infants younger than 1 year old who presented to Children's National Health System from 2012 to 2016 with cardiopulmonary resuscitation in progress. Medical records and the trauma registry were reviewed for relevant resuscitation information. Autopsy records provided the cause and manner of death, contributing factors to death, and evidence of injury. RESULTS Among 592 infants undergoing resuscitation during the study period, 34 infants (5.7%) presented in cardiac arrest. The average age on presentation was 101.2 days (standard deviation 78.7). Most of the patients (n = 32, 94.1%) died in the emergency department, with none surviving to discharge. Among the 32 infants for whom autopsy records were available, the cause of death was nonaccidental trauma in one patient (3.1%). CONCLUSIONS Infant OHCA had poor outcomes, with trauma as a rare etiology. In the absence of external signs of injury or known injury mechanism, immediate trauma team presence was not beneficial for these infants during the initial resuscitation phase.

The tumor microenvironment is an integral player in cancer initiation, tumor progression, response and resistance to anti‐cancer therapy. Understanding the complex interactions of tumor immune architecture (referred to as ‘immune contexture’) has therefore become increasingly desirable to guide our approach to patient selection, clinical trial design, combination therapies, and patient management. Quantitative image analysis based on multiplexed fluorescence immunohistochemistry and deep learning technologies are rapidly developing to enable researchers to interrogate complex information from the tumor microenvironment and find predictive insights into treatment response. Herein, we discuss current developments in multiplexed fluorescence immunohistochemistry for immune contexture analysis, and their application in immuno‐oncology, and discuss challenges to effectively use this technology in clinical settings. We also present a multiplexed image analysis workflow to analyse fluorescence multiplexed stained tumor sections using the Vectra Automated Digital Pathology System together with FCS express flow cytometry software. The benefit of this strategy is that the spectral unmixing accurately generates and analyses complex arrays of multiple biomarkers, which can be helpful for diagnosis, risk stratification, and guiding clinical management of oncology patients., This review discusses current developments in multiplexed fluorescent immunohistochemistry for immune contexture analysis, and their application in immuno‐oncology, and discusses challenges to effectively use this technology in clinical settings. We also present a multiplexed image analysis workflow to analyse fluorescence multiplexed stained tumor sections using the Vectra Automated Digital Pathology System together with FCS express flow cytometry software.

Oxygen saturation (SO2) in tissue is a crucially important physiological parameter with ubiquitous clinical utility in diagnosis, treatment, and monitoring, as well as widespread use as an invaluable preclinical research tool. Multispectral imaging can be used to visualize SO2 non-invasively, non-destructively and without contact in real-time using narrow spectral filter sets, but typically, these spectral filter sets are poorly suited to a specific clinical task, application, or tissue type. In this work, we demonstrate the merit of optimizing spectral filter sets for more accurate estimation of SO2. Using tissue modelling and simulated multispectral imaging, we demonstrate filter optimization reduces the root-mean-square-error (RMSE) in estimating SO2 by up to 37% compared with evenly spaced filters. Moreover, we demonstrate up to a 79% decrease in RMSE for optimized filter sets compared with filter sets chosen to minimize mutual information. Wider adoption of this approach will result in more effective multispectral imaging systems that can address specific clinical needs and consequently, more widespread adoption of multispectral imaging technologies in disease diagnosis and treatment.

Barrett's oesophagus is an acquired metaplastic condition that predisposes patients to the development of oesophageal adenocarcinoma, prompting the use of surveillance regimes to detect early malignancy for endoscopic therapy with curative intent. The currently accepted surveillance regime uses white light endoscopy together with random biopsies, but has poor sensitivity and discards information from numerous light-tissue interactions that could be exploited to probe structural, functional, and molecular changes in the tissue. Advanced optical methods are now emerging that are highly sensitive to these changes and hold potential to improve surveillance of Barrett's oesophagus if they can be applied endoscopically. The next decade will see some of these exciting new methods applied to surveillance of Barrett's oesophagus in new device architectures for the first time, potentially leading to a long-awaited improvement in the standard of care.

BackgroundPixatimod is a novel immunomodulatory agent which stimulates dendritic cells (DC) via Toll-Like Receptor 9 (TLR9) pathway to activate natural killer (NK) cells.1 It also enhances T cell infiltration into tumors when combined with PD1 inhibitors in vivo.2 We report on safety, pharmacodynamics (PD), and antitumor activity of pixatimod plus nivolumab in a cohort of previously treated MSS mCRC subjects.MethodsEligible MSS mCRC patients (ECOG≤1) with a median of 3 lines of previous treatment received 25 mg pixatimod once weekly as a 1-hour i.v. infusion plus nivolumab (240 mg, every other week) until disease progression or discontinuation due to intolerability. Primary and secondary objectives included the assessment of safety and antitumor activity per RECIST v1.1 at the recommended dose, and evidence of immune activation in peripheral blood mononuclear cells (PBMC), plasma cytokines/chemokines, and paired tumor tissue biopsies, where available.ResultsThirty-three subjects with MSS mCRC (42% male) started treatment. Median age was 58 (range 35–80), median number of previous lines of chemotherapy was 3 (range 1–6), ECOG PS 0/1 was 67%/33%, 64% had target liver metastases, and primary tumor site was right-sided/transverse colon in 21% and left-sided colon/rectum 79%. Median number of cycles completed was 2 (range 0–13). Treatment-related AEs led to treatment discontinuation in 2 patients (autoimmune hepatitis and pneumonitis). Ten Grade 3 treatment-related AEs were reported in 4 subjects (12%). Thirty subjects received at least one cycle of treatment (1-month), with 25 subjects having initial post-baseline assessment scans > 6 weeks (as per RECIST v1.1). Of these, 3 subjects had confirmed partial responses and 8 had stable disease. Lower Pan-immune-Inflammatory Value (PIV = Neutrophils x Platelets x Monocytes/Lymphocytes) at screening were associated with clinical benefit (PR/SD). Post-treatment increases in plasma IP-10 and IP-10/IL-8 ratio, effector memory (CD45RA-CCR7-) CD4+ and CD8+ T cells, and Ki-67 expression in CD4+ and CD8+ T cells from PBMC were also detected in the clinical benefit cohort compared to subjects with progressive disease. Conversely, plasma levels of IL-6 were significantly lower in patients with clinical benefit. Analyses of pre- & on-treatment biopsies from the only PR patient with available paired biopsies demonstrated an increase in T cell infiltration.ConclusionsPixatimod is well tolerated at 25 mg in combination with a standard dose of nivolumab. The efficacy signal and pharmacodynamic changes in MSS mCRC warrants further investigation of pixatimod plus nivolumab for this patient population.AcknowledgementsResearch Funding provided by Zucero Therapeutics Ltd and Bristol Myers Squibb (BMS), Australia.Trial RegistrationClinical trial informationACTRN12617001573347ReferencesBrennan TV, Lin L, Brandstadter JD, Rendell VR, Dredge K, Huang X, et al. Heparan sulfate mimetic PG545-mediated antilymphoma effects require TLR9-dependent NK cell activation. J Clin Invest 2016;126(1):207–19.Hammond E, Haynes NM, Cullinane C, Brennan TV, Bampton D, Handley P, et al. Immunomodulatory activities of pixatimod: emerging nonclinical and clinical data, and its potential utility in combination with PD-1 inhibitors. J Immunother Cancer 2018;6(1):54.Ethics ApprovalThe clinical trial entitled “An open-label, multi-centre Phase Ib study of the safety and tolerability of IV infused PG545 in combination with nivolumab in patients with advanced solid tumours with an expansion cohort in patients with metastatic pancreatic cancer. Protocol ZU545102” obtained ethics approval from the Royal Adelaide Hospital (HREC Reference number, HREC/17/RAH/195 and the CALHN Reference number, R20170515) and Bellberry Limited (Application No: 2018-08-695). All participants in the study gave informed consent before taking part in ZU545102.

Cervical cancer is a malignant transformation of keratinocytes initiated by the E7 oncoprotein of human papillomavirus (HPV). These tumors are characterized by keratinocyte hyperproliferation and are often infiltrated with activated CD8 T cells. HPV infection confers changes to gain immunological advantage to promote chronic infection, and these persist with malignant transformation. We investigated the relative importance of the many redundant mechanisms of cytotoxicity used by CD8 T cells to kill keratinocytes expressing HPV E7 oncoprotein using extended-duration time-lapse microscopy that allows examination of cell-to-cell interactions during killing. E7 expression by keratinocytes increased susceptibility to cell-mediated killing. However, while killing of non-transgenic keratinocytes was traditional, perforin-mediated, and caspase-dependent, E7-expression favored killing by perforin-independent, caspase-independent mechanisms. The roles of perforin, TNFα, IFNγ, Fas/FasL and PD1/PD-L1 were graded according to target cell survival to produce a hierarchy of killing mechanisms utilized in killing E7-expressing cells. TNFα was essential for perforin-mediated killing of E7-expressing cells, but not perforin-independent killing. IFNγ facilitated killing by Fas/FasL interaction, especially in the absence of perforin. Additionally, expression of E7 offered protection from killing by up regulation of PD-L1, Fas and FasL expression on keratinocytes promoting fight-back by target cells, resulting in effector cell death. This study shows that keratinocytes expressing E7 are highly susceptible to killing by CD8 T cells, but utilizing different armamentarium. Down-regulation of CD8 T cell cytotoxicity in HPV-related tumors may be due to suppression by E7-expressing keratinocytes. Immunotherapy for HPV-related cancers may be improved by suppression of PD-L1, or by suppression of FasL.

BACKGROUND Patients with prostate cancer and their providers face uncertainty as they consider adjuvant radiotherapy (ART) or salvage radiotherapy (SRT) after undergoing radical prostatectomy. The authors prospectively evaluated the impact of the Decipher test, which predicts metastasis risk after radical prostatectomy, on decision making for ART and SRT. METHODS A total of 150 patients who were considering ART and 115 who were considering SRT were enrolled. Providers submitted a management recommendation before processing the Decipher test and again at the time of receipt of the test results. Patients completed validated surveys on prostate cancer (PCa)-specific decisional effectiveness and PCa-related anxiety. RESULTS Before the Decipher test, observation was recommended for 89% of patients considering ART and 58% of patients considering SRT. After Decipher testing, 18% (95% confidence interval [95% CI], 12%-25%) of treatment recommendations changed in the ART arm, including 31% among high-risk patients; and 32% (95% CI, 24%-42%) of management recommendations changed in the salvage arm, including 56% among high-risk patients. Decisional Conflict Scale (DCS) scores were better after viewing Decipher test results (ART arm: median DCS before Decipher, 25 and after Decipher, 19 [P

Purpose The optimal management of men with prostate cancer at high risk of recurrence postradical prostatectomy is controversial. The clinical utility of the Decipher test was evaluated prospectively on postoperative treatment decisions and patient-reported outcomes. Methods and Materials In the study, 246 eligible men across 19 centers were enrolled. Patients were dichotomized into those considering adjuvant or salvage radiation therapy (ART or SRT). Participating providers submitted a management recommendation before and after receiving the Decipher test results. Treatment received within 12 months and a validated survey on prostate cancer–related anxiety were collected longitudinally. Results Pre-Decipher, treatment was recommended for 12% and 40% for the ART and SRT arms, respectively. Post-Decipher, 17% and 30% of treatment recommendations changed in the ART and SRT arms, respectively. Post-Decipher treatment recommendation was administered 78% and 76% of the time in the ART and SRT arms, respectively. Multivariable analysis confirmed that the Decipher score was an independent predictor for change in management for both adjuvant and salvage patients. The number needed to test to change management for one patient was 4. Cancer-specific anxiety decreased among Decipher risk categories in both arms. Conclusions Use of Decipher postradical prostatectomy test was associated with postoperative treatment decisions. Overall, high Decipher risk was associated with an increase in treatment intensity whereas low risk scores were associated with a decrease in therapy administered independent of clinical and pathologic risk factors.

Barrett’s oesophagus is an acquired condition in which columnar epithelium replaces the stratified squamous epithelium of the lining of the distal oesophagus, the pipe which connects the throat to the stomach. Crucially for early detection attempts, Barrett’s oesophagus predisposes patients to the development of oesophageal adenocarcinoma, prompting the use of surveillance regimes to detect early malignancy for endoscopic therapy with curative intent. The currently accepted surveillance regime uses white light endoscopy together with random biopsies, but has poor sensitivity and discards information from numerous light–tissue interactions that could be exploited to probe structural, functional, and molecular changes in the tissue. The potential to improve clinical outcomes by increasing contrast for dysplasia with advanced optical techniques has driven a great deal of research in this area. In light of the translational characteristics and translational barriers presented in Chap. 1, advanced optical techniques are reviewed here in the context of identifying the most promising techniques to take forward in our own work.

Multispectral imaging (MSI) enables both spatial (x, y) and spectral (wavelength, λ) information to be recorded. This allows delineation of fluorophores applied during molecular endoscopy based on their spectral properties, rather than a single intensity reading, allowing multiplexed fluorescence imaging of multiple targeted fluorophores. MSI also has the potential to image endogenous contrast due to wavelength-dependent light-tissue interactions. To address the clinical challenge of Barrett’s surveillance, a multispectral endoscope capable of acquisition of 9-band multispectral images in vivo was developed. This Chapter describes the design and validation of two alternative optical configurations of the device. The first, designed for multispectral fluorescence imaging, was demonstrated to be capable of accurately detecting fluorescent contrast agents both in well plates and in a realistic clinical scenario simulated using a whole ex vivo porcine oesophagus. The second, designed for multispectral reflectance imaging of endogenous contrast, has been applied in a first-in-human clinical trial, where the measured spectra showed promising differences between Barrett’s oesophagus and cancer tissue.

Optical imaging has tremendous potential for non-invasive detection and characterisation of diseased tissue using non-ionising radiation with wavelengths from 400–1000 nm. The approach benefits from: real-time analysis of tissue biochemistry based on sensitive interactions of light and tissue; compact, point-of-care and low-cost implementations compared to radiological imaging; and operation across a range of resolutions and depths that span over 4 orders of magnitude. Despite this potential, and the obvious enthusiasm for such technologies to reach clinical implementation, whilst many techniques have been approved for use in humans, relatively few have reached routine use in healthcare systems, begging the question: what is preventing their translation into healthcare?

In order to apply a novel optical imaging technique, a contrast mechanism must be combined with a device architecture. In this Chapter, emerging endoscopic device architectures are described, and their impact on clinical translation is considered. This is followed by a description of the device architecture we chose to develop, the work done to address its limitations, including an assessment of comb artefact removal and demosaicking algorithms, and the advantages this device architecture affords us.

Wheat germ agglutinin (WGA) is a lectin that shows differential binding to Barrett’s oesophagus and dysplasia. Imaging of fluorescently labelled WGA has the potential to increase the sensitivity and specificity of Barrett’s surveillance, but is confounded by tissue autofluorescence in the visible region where commercially available endoscopes are optimised for detection. To address this challenge, WGA was conjugated to a near-infrared fluorophore (IR800) for NIR fluorescence imaging, thus avoiding the visible autofluorescence background, and a bimodal endoscope capable of acquisition and coregistration of white light reflectance images for endoscopic guidance and of NIR fluorescence images for optical molecular imaging of WGA-IR800 was designed and built. This Chapter describes the design and development of this novel endoscope described and the preliminary biological validation carried out using ex vivo mouse and human tissues.

The pituitary gland is a pea-sized organ situated behind the ridge of the nose, attached to the base of the brain by a thin stalk. It is a key component of the endocrine system, responsible for hormonal control of other glands as well as many aspects of normal functioning including growth and blood pressure. The most common disease associated with the pituitary gland is pituitary adenoma, the development of a benign tumour. During surgical resection of pituitary adenoma, a delicate balance must be struck between maximising completeness of tumour resection and preserving endocrine function by conserving the normal pituitary. Currently, resection is guided by white light imaging, but it is often difficult to delineate the normal pituitary gland and the adenoma. This Chapter reviews the current standard of care for intraoperative imaging of pituitary adenoma and describes the development of a multispectral endoscope designed to address the clinical need for improved visualisation during resection.

The purpose of this study was to quantify health insurance misclassification among children treated at a pediatric trauma center and to determine factors associated with misclassification. Demographic, medical, and financial information were collected for patients at our institution between 2008 and 2010. Two health insurance variables were created: true (insurance on hospital admission) and payer (source of payment). Multivariable logistic regression was used to determine which factors were independently associated with health insurance misclassification. The two values of health insurance status were abstracted from the hospital financial database, the trauma registry, and the patient medical record. Among 3630 patients, 123 (3.4%) had incorrect health insurance designation. Misclassification was highest in patients who died: 13.9 per cent among all deaths and 30.8 per cent among emergency department deaths. The adjusted odds of misclassification were 6.7 (95% confidence interval: 1.7, 26.6) among patients who died and 16.1 (95% confidence interval: 3.2, 80.77) among patients who died in the emergency department. Using payer as a proxy for health insurance results in misclassification. Approaches are needed to accurately ascertain true health insurance status when studying the impact of insurance on treatment outcomes.

Natural killer (NK) cells are a heterogeneous population of innate lymphocytes whose potent anticancer properties make them ideal candidates for cellular therapeutic application. However, our lack of understanding of the role of NK cell diversity in antitumor responses has hindered advances in this area. In this study, we describe a new CD56(dim) NK cell subset characterized by the lack of expression of DNAX accessory molecule-1 (DNAM-1). Compared with CD56(bright) and CD56(dim)DNAM-1(pos) NK cell subsets, CD56(dim)DNAM-1(neg) NK cells displayed reduced motility, poor proliferation, lower production of interferon-γ, and limited killing capacities. Soluble factors secreted by CD56(dim)DNAM-1(neg) NK cells impaired CD56(dim)DNAM-1(pos) NK cell–mediated killing, indicating a potential inhibitory role for the CD56(dim)DNAM-1(neg) NK cell subset. Transcriptome analysis revealed that CD56(dim)DNAM-1(neg) NK cells constitute a new mature NK cell subset with a specific gene signature. Upon in vitro cytokine stimulation, CD56(dim)DNAM-1(neg) NK cells were found to differentiate from CD56(dim)DNAM-1(pos) NK cells. Finally, we report a dysregulation of NK cell subsets in the blood of patients diagnosed with Hodgkin lymphoma and diffuse large B-cell lymphoma, characterized by decreased CD56(dim)DNAM-1(pos)/CD56(dim)DNAM-1(neg) NK cell ratios and reduced cytotoxic activity of CD56(dim)DNAM-1(pos) NK cells. Altogether, our data offer a better understanding of human peripheral blood NK cell populations and have important clinical implications for the design of NK cell–targeting therapies.

Clinical workflows for the non-invasive detection and characterization of disease states could benefit from optical-imaging biomarkers. In this Perspective, we discuss opportunities and challenges towards the clinical implementation of optical-imaging biomarkers for the early detection of cancer by analysing two case studies: the assessment of skin lesions in primary care, and the surveillance of patients with Barrett’s oesophagus in specialist care. We stress the importance of technical and biological validations and clinical-utility assessments, and the need to address implementation bottlenecks. In addition, we define a translational roadmap for the widespread clinical implementation of optical imaging-technologies.

Hyperspectral imaging (HSI) enables visualisation of morphological and biochemical information, which could improve disease diagnostic accuracy. Unfortunately, the wide range of image distortions that arise during flexible endoscopy in the clinic have made integration of HSI challenging. To address this challenge, we demonstrate a hyperspectral endoscope (HySE) that simultaneously records intrinsically co-registered hyperspectral and standard-of-care white light images, which allows image distortions to be compensated computationally and an accurate hyperspectral data cube to be reconstructed as the endoscope moves in the lumen. Evaluation of HySE performance shows excellent spatial, spectral and temporal resolution and high colour fidelity. Application of HySE enables: quantification of blood oxygenation levels in tissue mimicking phantoms; differentiation of spectral profiles from normal and pathological ex vivo human tissues; and recording of hyperspectral data under freehand motion within an intact ex vivo pig oesophagus model. HySE therefore shows potential for enabling HSI in clinical endoscopy., Hyperspectral imaging (HSI) enables recording both morphological and biochemical information, but image acquisition time and geometric distortions limit its clinical applicability. Here the authors overcome these challenges with an endoscope combining HSI and white light to correct for image distortion during freehand operation.

Preclinical studies have suggested that purified populations of CD1c (BDCA-1) blood-derived dendritic cells (BDC) loaded with tumor-specific peptides may be a feasible option for prostate cancer immunotherapy. We performed an open-label dose-finding Phase I study to evaluate the safe use of CD1c BDC in patients with advanced metastatic hormone refractory prostate cancer. HLA-A*0201-positive patients with advanced metastatic prostate cancer were recruited and consented. The vaccine was manufactured by pulsing autologous CD1c BDC, prepared by magnetic bead immunoselection from apheresed peripheral blood mononuclear cells, with a cocktail of HLA-A*0201-restricted peptides (prostate-specific antigen, prostate acid phosphatase, prostate specific membrane antigen, and control influenza peptide) and keyhole limpet hemocyanin. The vaccine was administered intradermally or intravenously and peripheral blood was taken at predetermined intervals for clinical and immunologic monitoring. The vaccine was manufactured with a median purity of 82% CD1c BDC and administered successfully to 12 patients. Each patient received between 1 and 5 × 10 fresh CD1c BDC on day 0, followed by cryopreserved product in the same dose on days 28 and 56. The vaccine was well tolerated in all patients, with the most frequent adverse events being grade 1-2 fever, pain, or injection-site reactions. Vaccination with CD1c BDC is therefore feasible, safe, and well tolerated in patients with advanced-stage metastatic prostate cancer.

Tritium tracers are frequently used in biological assays during the drug discovery process because of their high specific activity and relative ease of synthesis. However, this high specific activity, along with other contributing factors, can lead to an increased rate of radiolytic decomposition. As a result, following long-term storage tritium tracers often require purification. Understanding the elements that cause radiolytic decomposition is extremely important to extend the storage life, and consequently reduce unnecessary inventory purifications. One of these elements is the presence of water in tritium tracers. Upon investigation, it was discovered that aside from the relatively common tritium/water exchange that could occur, residual water could also contribute significantly to the decomposition of tritium tracers. A near-infrared method was developed utilizing a portable device to measure the water content in tritium tracers rapidly and without sample destruction. This method proved to be quick, efficient, and achieved an error less than 5% compared to that of traditional Karl Fischer titration. Method validation was performed and good accuracy, linearity, limit of detection and quantitation were all established.

A multispectral endoscope capable of simultaneous reflectance and fluorescence imaging was developed based on spectrally resolved detector arrays. The endoscope can simultaneous image and unmix oxy/deoxygenated blood and two fluorescent dyes.

In many hospitals, family members are separated from their children during the early phases of trauma care. Including family members during this phase of trauma care varies by institution and is limited by concerns for adverse effects on clinical care.The aim of this study is to evaluate the effect of family presence (FP) on advanced trauma life support primary and secondary survey task performance by pediatric trauma teams. We hypothesized that trauma care with FP would be noninferior to care when families were absent.We performed a retrospective video review of consecutive pediatric trauma evaluations. Family presence status was determined by availability of the family.The study was conducted at an American College of Surgeons-designated level I pediatric trauma center that serves the Washington, DC, metropolitan area.Participants included patients younger than 16 years of age who met trauma activation criteria and were evaluated by the trauma team in our emergency department.We compared task performance between patients with and without FP.Video recordings of 135 trauma evaluations were reviewed. Family was present for 88 (65%) evaluations. Patients with FP were younger (mean age, 6.4 years [SD = 4.1] vs 9.0 years [SD = 4.9]; P0.001) and more likely to have sustained blunt injuries (95% vs 85%, P = 0.03). Noninferiority of frequency and timeliness of completion of all primary survey tasks were confirmed for evaluations with FP. Noninferiority of frequencies of secondary survey task completion was confirmed for most tasks except for examination of the neck, pelvis, and upper extremities. Family members did not directly interfere with patient care in any case.Performance of most advanced trauma life support tasks during pediatric trauma evaluation was not worsened by FP. Our data provide additional evidence supporting FP during the acute management of injured children.

IMPORTANCE In many hospitals, family members are separated from their children during the early phases of trauma care. Including family members during this phase of trauma care varies by institution and is limited by concerns for adverse effects on clinical care. OBJECTIVE The aim of this study is to evaluate the effect of family presence (FP) on advanced trauma life support primary and secondary survey task performance by pediatric trauma teams. We hypothesized that trauma care with FP would be noninferior to care when families were absent. DESIGN We performed a retrospective video review of consecutive pediatric trauma evaluations. Family presence status was determined by availability of the family. SETTING The study was conducted at an American College of Surgeons-designated level I pediatric trauma center that serves the Washington, DC, metropolitan area. PARTICIPANTS Participants included patients younger than 16 years of age who met trauma activation criteria and were evaluated by the trauma team in our emergency department. OUTCOME MEASURES We compared task performance between patients with and without FP. RESULTS Video recordings of 135 trauma evaluations were reviewed. Family was present for 88 (65%) evaluations. Patients with FP were younger (mean age, 6.4 years [SD = 4.1] vs 9.0 years [SD = 4.9]; P < 0.001) and more likely to have sustained blunt injuries (95% vs 85%, P = 0.03). Noninferiority of frequency and timeliness of completion of all primary survey tasks were confirmed for evaluations with FP. Noninferiority of frequencies of secondary survey task completion was confirmed for most tasks except for examination of the neck, pelvis, and upper extremities. Family members did not directly interfere with patient care in any case. CONCLUSIONS Performance of most advanced trauma life support tasks during pediatric trauma evaluation was not worsened by FP. Our data provide additional evidence supporting FP during the acute management of injured children.

Long-term anticoagulant therapy with non-valvular atrial fibrillation (AF) is essential to prevent thromboembolic complications, especially ischemic stroke. This study examines medium-term persistence in AF patients using a non-vitamin-K antagonist oral anticoagulant drug (NOAC).We assessed national Pharmaceutical Benefit Scheme records December 2013 through September 2016 for initial prescription of a NOAC in a 10% random sample of concessional patients. Key outcome measures were: (a) proportions filling first repeat prescription, (b) proportions persisting with NOAC over 12 and 30 months and (c) proportions switching to another NOAC or warfarin.A total of 8656 patients with AF initiated a NOAC (3352 apixaban, 1340 dabigatran, 3964 rivaroxaban). Mean age was 77 years, 53% male; 91% collected the first repeat prescription for any NOAC, 70% and 57% collected any NOAC or subsequent warfarin prescription over 12 months and 30 months respectively; 8.9% had switched to warfarin. The proportions switching from apixaban, dabigatran and rivaroxaban to a different NOAC were 14%, 31% and 17% respectively. In a regression model adjusting for age, gender and comorbidity, apixaban-initiated patients over 30 months were 28% more likely to persist with any anticoagulant therapy compared with dabigatran-initiated patients (hazard ratio [95% CI] 1.28 [1.16-1.42]) and 15% more likely to persist compared with rivaroxaban-initiated (1.15 [1.06-1.24]). Rivaroxaban-initiated patients were 12% more likely to persist compared with dabigatran-initiated patients (1.12 [1.02-1.24]).Long-term persistence with anticoagulation in patients with AF remains a concern, even with NOACs. Patients initiated to apixaban appear to experience better medium-term persistence compared with rivaroxaban or dabigatran.

Multispectral imaging has the potential to improve sensitivity and specificity in biomedical imaging through simultaneous acquisition of both morphological (spatial) and chemical (spectral) information. Performing multispectral imaging in real time with spectrally resolved detector arrays (SRDAs), for example in endoscopy or intraoperative imaging, requires a direct trade off between spatial and spectral resolution. We sought to quantitatively assess the impact of spectral band selection on contrast agent detection in fluorescence endoscopic imaging. As a proof of concept, we measured the ‘ground truth’ spectra from a dilution series of a single near-infrared fluorescent contrast agent using a spectrometer incorporated into the detection path of our endoscope. We then modeled the influence of an SRDA on these spectra and calculated the theoretical endmembers associated with reflectance and fluorescence signals from the pure contrast agent. To test the accuracy of our model, we incorporated into the same endoscope an off-the-shelf SRDA with a 3x3 filter deposition pattern of 9 spectral bands. After spectral unmixing using the modeled endmembers, the amplitude of the fluorescence recorded with the SRDA compared favorably with the amplitude of fluorescence derived from the ‘ground truth’ spectra recorded with the spectrometer. In the future, this approach could be used to minimize the number of spectral bands required in a given imaging system and hence maximize the spatial resolution of the multispectral camera.