David Alan Schoenfeld

Background: Recent meta-analyses of randomized controlled trials (RCTs) have raised concerns that treatment with omega-3 fatty acids may increase risk of atrial fibrillation (AF). However, these meta-analyses included at most eight trials. The aim of this current meta-analysis was to expand the search by including other eligible omega-3 RCTs with AF incidence data, incorporating both published and unpublished data. Methods: Eligible studies were RCTs investigating daily doses of ≥500 mg/d of docosahexaenoic acid (DHA) and/or eicosapentaenoic acid (EPA). Additional inclusion criteria included ≥12 months treatment with EPA/DHA, participants ≥ 50 years of age, and where possible, the absence of known AF/atrial flutter at baseline. The primary outcome was occurrence of new-onset AF. Our primary hypothesis was that risk for AF would simultaneously depend on both omega-3 dose (above or below 1500 mg/d) and background cardiovascular disease (CVD) risk status, and that their combined impact on AF risk would be synergistic. Results: A total of 34 RCTs (36 datasets; n=114,326) were included in this meta-analysis. Only studies including patients at high-risk for CVD who were treated with high-doses of EPA/DHA (>1500 mg/day) showed a statistically significant increase in AF risk with a pooled odds ratio (OR) of 1.48 (95% CI, 1.21-1.81) and an absolute risk difference of 0.8% (0.40-1.1%). None of the other three groups showed statistically significant levels of AF risk (ORs 1.07 (high risk, low dose), 1.06 (low risk, low dose) and 0.95 (low risk, high dose). Conclusion: This meta-analysis suggests that treatment with EPA/DHA is most likely to increase risk for AF in patients at high-risk for CVD who are treated with high doses of EPA/DHA. The risk for AF should be balanced against the benefits of EPA/DHA in making treatment decisions.

Background: Adoptive cell therapy using tumor-infiltrating lymphocytes (TIL) is approved for the treatment of advanced melanoma but is limited by the need for patients to undergo surgical tumor resection. Malignant pleural effusions (MPE) may represent a more accessible source of tumor-reactive T cells. Here, we characterize the cellular composition as well as the transcriptional and functional properties of T cells from MPE compared with pulmonary metastasis and blood from a patient with melanoma. Methods: The immune cellular composition was immunophenotyped by high-dimensional flow cytometry from synchronously collected MPE, a lung metastasis, and blood from a patient with metastatic melanoma. Sorted CD3+ T cells were profiled by single-cell RNA sequencing (scRNA-seq) and T cell receptor sequencing (scTCR-seq). TCR reactivity to autologous tumor was evaluated through in vitro activation assays with TCR-transduced Jurkat and autologous cancer cells. The killing capacity of ex vivo expanded T cells of autologous cancer cells was assessed through in vitro cytotoxicity assays. Results: MPE had higher proportions of CD45+ immune cells and CD3+ T cells (70.5% vs 50%) compared with tumor and was enriched for effector CD8+ T cells, CCR7-CD45RA- effector memory CD4+ T cells, and quiescent CD25highCD127low regulatory CD4+ T cells. MPE T cells exhibited lower levels of co-inhibitory receptors (PD-1, LAG-3, TIGIT, TIM-3) expression relative to tumor. ScRNA-seq showed enrichment of NK-like effector CD8+ T cells in MPE. Pseudotime analysis indicated that MPE T cells were less exhausted than tumor T cells. The clonal repertoire of MPE and tumor highly overlapped, including 62.2% of predicted neoantigen-specific (NeoTCR) clonotypes. Notably, clonally-related NeoTCR T cells in MPE exhibited higher cytotoxic and stemness, and lower exhaustion signatures compared with sister clones in the tumor. Two of four selected NeoTCR clonotypes transduced in Jurkat cells demonstrated MHC class I-restricted reactivity in co-culture with autologous cancer cells. MPE T cells also readily expanded in the presence of high-dose IL-2 and demonstrated MHC class I-dependent killing of autologous cancer cells. Conclusions: MPE harbors polyclonal, tumor-reactive T cells with lower features of terminal exhaustion and higher cytotoxic potential relative to tumor T cells. MPE may therefore serve as a more accessible source for TIL therapy.

For single arm trials, a treatment is evaluated by comparing an outcome estimate to historically reported outcome estimates. Such a historically controlled trial is often analyzed as if the estimates from previous trials were known without variation and there is no trial-to-trial variation in their estimands. We develop a test of treatment efficacy and sample size calculation for historically controlled trials that considers these sources of variation. We fit a Bayesian hierarchical model, providing a sample from the posterior predictive distribution of the outcome estimand of a new trial, which, along with the standard error of the estimate, can be used to calculate the probability that the estimate exceeds a threshold. We then calculate criteria for statistical significance as a function of the standard error of the new trial and calculate sample size as a function of difference to be detected. We apply these methods to clinical trials for amyotrophic lateral sclerosis using data from the placebo groups of 16 trials. We find that when attempting to detect the small to moderate effect sizes usually assumed in amyotrophic lateral sclerosis clinical trials, historically controlled trials would require a greater total number of patients than concurrently controlled trials, and only when an effect size is extraordinarily large is a historically controlled trial a reasonable alternative. We also show that utilizing patient level data for the prognostic covariates can reduce the sample size required for a historically controlled trial. This article quantifies when historically controlled trials would not provide any sample size advantage, despite dispensing with a control group.

The accelerated failure time (AFT) model is a common method for estimating the effect of a covariate directly on a patient’s survival time. In some cases, death is the final (absorbing) state of a progressive multi-state process, however when the survival time for a subject is censored, traditional AFT models ignore the intermediate information from the subject’s most recent disease state despite its relevance to the mortality process. We propose a method to estimate an AFT model for survival time to the absorbing state that uses the additional data on intermediate state transition times as auxiliary information when a patient is right censored. The method extends the Gehan AFT estimating equation by conditioning on each patient’s censoring time and their disease state at their censoring time. With simulation studies, we demonstrate that the estimator is empirically unbiased, and can improve efficiency over commonly used estimators that ignore the intermediate states.

Rejection affects greater than 80% of face transplants, yet no diagnostic criteria for antibody-mediated rejection (AMR) following face transplantation have been established. Given that different treatment strategies are required to address AMR and T cell–mediated rejection (TCMR), there is a critical need to delineate the features that can differentiate these two alloimmune responses. Here, we report the longitudinal immunological examination of what we believe to be the first and only highly sensitized recipient of a crossmatch-positive face transplant up to 4 years following transplantation. We conducted gene expression profiling on allograft biopsies collected during suspected AMR and TCMR episodes as well as during 5 nonrejection time points. Our data suggest that there are distinctive molecular features in AMR, characterized by overexpression of endothelial-associated genes, including ICAM1 , VCAM1 , and SELE . Although our findings are limited to a single patient, these findings highlight the potential importance of developing and implementing molecular markers to differentiate AMR from TCMR to guide clinical management. Furthermore, our case illustrates that molecular assessment of allograft biopsies offers the potential for new insights into the mechanisms underlying rejection. Finally, our medium-term outcomes demonstrate that face transplantation in a highly sensitized patient with a positive preoperative crossmatch is feasible and manageable.

Successful induction of allograft tolerance has been achieved in nonhuman primates (NHPs) and humans via induction of transient hematopoietic chimerism. Since allograft tolerance was achieved in these recipients without durable chimerism, peripheral mechanisms are postulated to play a major role. Here, we report our studies of T cell immunity in NHP recipients that achieved long-term tolerance versus those that rejected the allograft (AR). All kidney, heart, and lung transplant recipients underwent simultaneous or delayed donor bone marrow transplantation (DBMT) following conditioning with a nonmyeloablative regimen. After DBMT, mixed lymphocyte culture with CFSE consistently revealed donor-specific loss of CD8 ⁺ T cell responses in tolerant (TOL) recipients, while marked CD4 ⁺ T cell proliferation in response to donor antigens was found to persist. Interestingly, a significant proportion of the proliferated CD4 ⁺ cells were FOXP3 ⁺ in TOL recipients, but not in AR or naive NHPs. In TOL recipients, CD4 ⁺ FOXP3 ⁺ cell proliferation against donor antigens was greater than that observed against third-party antigens. Finally, the expanded Tregs appeared to be induced Tregs (iTregs) that were converted from non-Tregs. These data provide support for the hypothesis that specific induction of iTregs by donor antigens is key to long-term allograft tolerance induced by transient mixed chimerism.