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Vonderhaar EP, Dwinell MB, Craig BT. Targeted immune activation in pediatric solid tumors: opportunities to complement local control approaches. Front Immunol 2023; 14:1202169. [PMID: 37426669 PMCID: PMC10325564 DOI: 10.3389/fimmu.2023.1202169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Surgery or radiation therapy is nearly universally applied for pediatric solid tumors. In many cases, in diverse tumor types, distant metastatic disease is present and evades surgery or radiation. The systemic host response to these local control modalities may lead to a suppression of antitumor immunity, with potential negative impact on the clinical outcomes for patients in this scenario. Emerging evidence suggests that the perioperative immune responses to surgery or radiation can be modulated therapeutically to preserve anti-tumor immunity, with the added benefit of preventing these local control approaches from serving as pro-tumorigenic stimuli. To realize the potential benefit of therapeutic modulation of the systemic response to surgery or radiation on distant disease that evades these modalities, a detailed knowledge of the tumor-specific immunology as well as the immune responses to surgery and radiation is imperative. In this Review we highlight the current understanding of the tumor immune microenvironment for the most common peripheral pediatric solid tumors, the immune responses to surgery and radiation, and current evidence that supports the potential use of immune activating agents in the perioperative window. Finally, we define existing knowledge gaps that limit the current translational potential of modulating perioperative immunity to achieve effective anti-tumor outcomes.
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Affiliation(s)
- Emily P. Vonderhaar
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
- Center for Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Michael B. Dwinell
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
- Center for Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Brian T. Craig
- Center for Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
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2
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Carlton EF, Gebremariam A, Maddux AB, McNamara N, Barbaro RP, Cornell TT, Iwashyna TJ, Prosser LA, Zimmerman J, Weiss S, Prescott HC. New and Progressive Medical Conditions After Pediatric Sepsis Hospitalization Requiring Critical Care. JAMA Pediatr 2022; 176:e223554. [PMID: 36215045 PMCID: PMC9552050 DOI: 10.1001/jamapediatrics.2022.3554] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/20/2022] [Indexed: 12/15/2022]
Abstract
Importance Children commonly experience physical, cognitive, or emotional sequelae after sepsis. However, little is known about the development or progression of medical conditions after pediatric sepsis. Objective To quantify the development and progression of 4 common conditions in the 6 months after sepsis and to assess whether they differed after hospitalization for sepsis vs nonsepsis among critically ill children. Design, Setting, and Participants This cohort study of 101 511 children (<19 years) with sepsis or nonsepsis hospitalization used a national administrative claims database (January 1, 2010, to June 30, 2018). Data management and analysis were conducted from April 1, 2020, to July 7, 2022. Exposures Intensive care unit hospitalization for sepsis vs all-cause intensive care unit hospitalizations, excluding sepsis. Main Outcomes and Measures Primary outcomes were the development of 4 target conditions (chronic respiratory failure, seizure disorder, supplemental nutritional dependence, and chronic kidney disease) within 6 months of hospital discharge. Secondary outcomes were the progression of the 4 target conditions among children with the condition before hospitalization. Outcomes were identified via diagnostic and procedural codes, durable medical equipment codes, and prescription medications. Differences in the development and the progression of conditions between pediatric patients with sepsis and pediatric patients with nonsepsis who survived intensive care unit hospitalization were assessed using logistic regression with matching weights. Results A total of 5150 survivors of pediatric sepsis and 96 361 survivors of nonsepsis intensive care unit hospitalizations were identified; 2593 (50.3%) were female. The median age was 9.5 years (IQR, 3-15 years) in the sepsis cohort and 7 years (IQR, 2-13 years) in the nonsepsis cohort. Of the 5150 sepsis survivors, 670 (13.0%) developed a new target condition, and 385 of 1834 (21.0%) with a preexisting target condition had disease progression. A total of 998 of the 5150 survivors (19.4%) had development and/or progression of at least 1 condition. New conditions were more common among sepsis vs nonsepsis hospitalizations (new chronic respiratory failure: 4.6% vs 1.9%; odds ratio [OR], 2.54 [95% CI, 2.19-2.94]; new supplemental nutritional dependence: 7.9% vs 2.7%; OR, 3.17 [95% CI, 2.80-3.59]; and new chronic kidney disease: 1.1% vs 0.6%; OR, 1.65 [95% CI, 1.25-2.19]). New seizure disorder was less common (4.6% vs 6.0%; OR, 0.77 [95% CI, 0.66-0.89]). Progressive supplemental nutritional dependence was more common (1.5% vs 0.5%; OR, 2.95 [95% CI, 1.60-5.42]), progressive epilepsy was less common (33.7% vs 40.6%; OR, 0.74 [95% CI, 0.65-0.86]), and progressive respiratory failure (4.4% vs 3.3%; OR, 1.35 [95% CI, 0.89-2.04]) and progressive chronic kidney disease (7.9% vs 9.2%; OR, 0.84 [95% CI, 0.18-3.91]) were similar among survivors of sepsis vs nonsepsis admitted to an intensive care unit. Conclusions and Relevance In this national cohort of critically ill children who survived sepsis, 1 in 5 developed or had progression of a condition of interest after sepsis hospitalization, suggesting survivors of pediatric sepsis may benefit from structured follow-up to identify and treat new or worsening medical comorbid conditions.
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Affiliation(s)
- Erin F. Carlton
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Acham Gebremariam
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Aline B. Maddux
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora
| | - Nancy McNamara
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Ryan P. Barbaro
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Timothy T. Cornell
- Lucille Packard Children’s Hospital, Stanford University, Palo Alto, California
| | - Theodore J. Iwashyna
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Lisa A. Prosser
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Jerry Zimmerman
- Seattle Children’s Hospital, Harborview Medical Center, University of Washington School of Medicine, Seattle
| | - Scott Weiss
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Children’s Hospital of Philadelphia, Pediatric Sepsis Program, Philadelphia, Pennsylvania
| | - Hallie C. Prescott
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor
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3
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Zhou Y, Wang Y, Li Q, Sheng H, Mao E, Jiang W. The effects of early restrictive fluid resuscitation on the clinical outcomes in sepsis patients. Am J Transl Res 2021; 13:11482-11490. [PMID: 34786074 PMCID: PMC8581844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/11/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To investigate the effects of early restrictive fluid resuscitation (RFR) on the clinical outcomes in sepsis patients. METHODS A total of 122 sepsis patients admitted to our hospital were recruited for this study and divided into a study group (the SG, n=56) and a control group (the CG, n=66) according to the treatment method each patient was administered. The SG was administered early RFR, and the CG was administered adequate fluid resuscitation. The clinical data were analyzed retrospectively in both groups. The total infusion volumes, the hemorrhage amounts, the urine outputs, and the Acute Physiology and Chronic Health Evaluation (APACHE II) scores were compared between the two groups. In addition, the heart rates, the mean arterial pressure levels, the central venous pressure levels, and the cardiac function indices were compared between the two groups at 1-7 days after the procedures. The survival and the complication incidence rates were followed up. RESULTS The SG showed significantly lower heart rates and mean arterial pressure levels and higher central venous pressure levels than the CG at 1-7 days after the procedures (P<0.05). The cardiac troponin, N-terminal brain pro-natriuretic peptide, and C-reactive protein levels at 3-7 days after the procedures in the SG were significantly lower than the levels in the CG (P<0.05). The cardiac output, stroke volume, and left ventricular ejection fraction scores in the SG were significantly higher than they were in the CG (P<0.05). The survival rate in the SG was significantly higher than it was in the CG at 16, 32, and 64 days after the procedures (P<0.05). The incidence of complications in the SG was lower than it was in the CG (P<0.05). CONCLUSION Early RFR can remarkably improve the clinical outcomes, the myocardial injury and survival rates, and the multiple complications incidence rate in sepsis patients.
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Affiliation(s)
- Yuhua Zhou
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of MedicineShanghai 200025, China
| | - Yihui Wang
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of MedicineShanghai 200025, China
| | - Qingtian Li
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of MedicineShanghai 200025, China
| | - Huiqiu Sheng
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of MedicineShanghai 200025, China
| | - Enqiang Mao
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of MedicineShanghai 200025, China
| | - Weisong Jiang
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of MedicineShanghai 200025, China
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Mualla NM, Hussain MR, Akrmah M, Malik P, Bashir S, Lin JJ. The Impact of Postoperative Complications on Long-Term Oncological Outcomes Following Curative Resection of Colorectal Cancer (Stage I-III): A Systematic Review and Meta-Analysis. Cureus 2021; 13:e12837. [PMID: 33628695 PMCID: PMC7896484 DOI: 10.7759/cureus.12837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background and objective The incidence of post-surgical complications (PSCs) after curative resection of non-metastatic colorectal cancer (CRC) is very widespread and evident. Some studies suggest that PSCs often predict poor long-term oncological outcomes. However, the available data on the topic is often controversial. The aim of this systematic review and meta-analysis was to study the effect of postoperative complications (POCs) on long-term oncological outcomes following curative resection of non-metastatic (stage I-III) CRC. Methods A comprehensive search of MEDLINE® and Excerpta Medica dataBASE (EMBASE) databases was performed via the Ovid platform, by using controlled vocabulary as well as natural language terms for POCs, outcomes, and CRC. Two authors independently screened the studies and extracted data. Conflicts were resolved by discussion among authors and also independently with the help of a third author. Meta-analysis was performed using a random-effects model (REM) to calculate pooled estimates for overall survival (OS), disease-free survival (DFS), and overall recurrence. Results Overall, 3,836 studies were initially screened, and 16 studies involving 37,192 patients were ultimately selected for final inclusion in the analysis. Meta-analysis of these studies showed that PSCs following non-metastatic CRC surgery predicted worse OS rates [hazard ratio (HR): 1.36; 95% CI: 1.15-1.61; p<0.00001], DFS (HR: 1.41; 95% CI: 1.11-1.80; p<0.00001), and overall recurrence (HR: 1.19; 95% CI: 1.04-1.37; p=0.01). Conclusion Based on our findings, PSCs predict poor OS rates, DFS, and overall recurrence following curative resection of non-metastatic CRC.
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Affiliation(s)
- Noor M Mualla
- Public Health, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Maryam R Hussain
- Epidemiology, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Preeti Malik
- Public Health, Icahn School of Medicine at Mount Sinai, New York, USA.,Neurology, Massachusetts General Hospital, Andover, USA
| | - Sadia Bashir
- Internal Medicine, Pakistan Medical and Dental Council and University of Health Sciences, Lahore, PAK
| | - Jenny J Lin
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
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Watt SK, Fransgaard T, Degett TH, Thygesen LC, Benfield T, Knudsen JD, Fuursted K, Jensen TG, Dessau RB, Schønheyder HC, Møller JK, Gögenur I. Associations between blood cultures after surgery for colorectal cancer and long-term oncological outcomes. Br J Surg 2019; 107:310-315. [PMID: 31755092 DOI: 10.1002/bjs.11372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/11/2019] [Accepted: 08/27/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Systemic inflammation following curative surgery for colorectal cancer may be associated with increased risk of recurrence. [Correction added on 29 November 2019, after first online publication: text amended for accuracy.] This study investigated whether a clinically suspected infection, for which blood cultures were sent within 30 days after surgery for colorectal cancer, was associated with long-term oncological outcomes. METHODS This register-based national cohort study included all Danish residents undergoing surgery with curative intent for colorectal cancer between January 2003 and December 2013. Patients who developed recurrence or died within 180 days after surgery were not included. Associations between blood cultures taken within 30 days after primary surgery and overall survival, disease-free survival and recurrence-free survival were analysed using Cox regression models adjusted for relevant clinical confounders, including demographic data, cancer stage, co-morbidity, blood transfusion, postoperative complications and adjuvant chemotherapy. RESULTS The study included 21 349 patients, of whom 3390 (15·9 per cent) had blood cultures taken within 30 days after surgery. Median follow-up was 5·6 years. Patients who had blood cultures taken had an increased risk of all-cause mortality (hazard ratio (HR) 1·27, 95 per cent c.i. 1·20 to 1·35; P < 0·001), poorer disease-free survival (HR 1·22, 1·16 to 1·29; P < 0·001) and higher risk of recurrence (HR 1·15, 1·07 to 1·23; P < 0·001) than patients who did not have blood cultures taken. CONCLUSION A clinically suspected infection requiring blood cultures within 30 days of surgery for colorectal cancer was associated with poorer oncological outcomes.
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Affiliation(s)
- S K Watt
- Department of Surgery, Zealand University Hospital Køge/Roskilde, Køge, Denmark
| | - T Fransgaard
- Department of Surgery, Zealand University Hospital Køge/Roskilde, Køge, Denmark
| | - T H Degett
- Department of Surgery, Zealand University Hospital Køge/Roskilde, Køge, Denmark
| | - L C Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - T Benfield
- Department of Infectious Diseases, Copenhagen University Hospital, Amager/Hvidovre, Hvidovre, Denmark
| | - J D Knudsen
- Department of Clinical Microbiology, Copenhagen University Hospital Amager/Hvidovre Hospital, Hvidovre, Denmark
| | - K Fuursted
- Department of Bacteria, Parasites and Fungi, Statens Serum Institute, Copenhagen, Denmark
| | - T G Jensen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - R B Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - H C Schønheyder
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark
| | - J K Møller
- Department of Clinical Microbiology, Lillebaelt Hospital, Vejle, Denmark
| | - I Gögenur
- Department of Surgery, Zealand University Hospital Køge/Roskilde, Køge, Denmark
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Arnarson Ö, Butt-Tuna S, Syk I. Postoperative complications following colonic resection for cancer are associated with impaired long-term survival. Colorectal Dis 2019; 21:805-815. [PMID: 30884061 DOI: 10.1111/codi.14613] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 03/12/2019] [Indexed: 12/15/2022]
Abstract
AIM Surgery for colorectal cancer is associated with a high incidence of postoperative complications. The aim of this study was to analyse whether postoperative complications following radical resection for colorectal cancer are associated with increased recurrence rate and impaired survival. METHOD Patients operated for colon cancer between 2007 and 2009 with curative intent were identified through the Swedish Colorectal Cancer Registry. The cohort was divided into three subgroups: patients who developed severe postoperative complications, patients who developed non-severe complications and patients who did not develop any complication (controls). RESULTS Of 6779 patients included in the study, 640 (9%) developed severe complications, 994 (15%) non-severe complications and 5145 (76%) had no complications. The 5-year overall survival rate was 60.3% in the severe complication group, 64.2% in the non-severe complication group and 72.8% in the control group (P < 0.01). The 3-year disease-free survival rate was 66.8%, 70.9% and 77.8% respectively (P < 0.01). The recurrence rate did not differ between the three groups. In multivariate analysis, both severe and non-severe complications were found to be risk factors for decreased overall survival at 5 years [hazard ratio (HR) 1.38, 95% CI 1.47-1.92, and HR 1.18, 95% CI 1.27-1.60 respectively; P < 0.05) as well as for decreased 3-year disease-free survival (HR 1.37, 95% CI 1.14-1.65, and HR 1.26, 95% CI 1.08-1.48 respectively; P < 0.05). CONCLUSION Complications after colonic resection for cancer are associated with impaired 5-year overall survival and 3-year disease-free survival and exhibit more severe postoperative complications, mainly via mechanisms other than cancer recurrence.
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Affiliation(s)
- Ö Arnarson
- Department of Surgery, Skane University Hospital, Malmo, Sweden
| | - S Butt-Tuna
- Department of Surgery, Skane University Hospital, Malmo, Sweden
| | - I Syk
- Lund University, Lund, Sweden.,Department of Surgery, Skane University Hospital, Malmo, Sweden
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Bakos O, Lawson C, Rouleau S, Tai LH. Combining surgery and immunotherapy: turning an immunosuppressive effect into a therapeutic opportunity. J Immunother Cancer 2018; 6:86. [PMID: 30176921 PMCID: PMC6122574 DOI: 10.1186/s40425-018-0398-7] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/16/2018] [Indexed: 12/27/2022] Open
Abstract
Background Cancer surgery is necessary and life-saving. However, the majority of patients develop postoperative recurrence and metastasis, which are the main causes of cancer-related deaths. The postoperative stress response encompasses a broad set of physiological changes that have evolved to safeguard the host following major tissue trauma. These stress responses, however, intersect with cellular mediators and signaling pathways that contribute to cancer proliferation. Main Previous descriptive and emerging mechanistic studies suggest that the surgery-induced prometastatic effect is linked to impairment of both innate and adaptive immunity. Existing studies that combine surgery and immunotherapies have revealed that this combination strategy is not straightforward and patients have experienced both therapeutic benefit and drawbacks. This review will specifically assess the immunological pathways that are disrupted by oncologic surgical stress and provide suggestions for rationally combining cancer surgery with immunotherapies to improve immune and treatment outcomes. Short conclusion Given the prevalence of surgery as frontline therapy for solid cancers, the emerging data on postoperative immunosuppression and the rapid development of immunotherapy for oncologic treatment, we believe that future targeted studies of perioperative immunotherapy are warranted.
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Affiliation(s)
- Orneala Bakos
- Department of Anatomy and Cell Biology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Christine Lawson
- Department of Anatomy and Cell Biology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Samuel Rouleau
- Department of Anatomy and Cell Biology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Lee-Hwa Tai
- Department of Anatomy and Cell Biology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada. .,Centre de Recherche Clinique de Centre Hospitalier de l'Université de Sherbrooke (CHUS), Room 4853, 3001, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada.
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Tai LH, Ananth AA, Seth R, Alkayyal A, Zhang J, de Souza CT, Staibano P, Kennedy MA, Auer RC. Correction to: Sepsis increases perioperative metastases in a murine model. BMC Cancer 2018; 18:437. [PMID: 29665786 PMCID: PMC5905137 DOI: 10.1186/s12885-018-4248-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Lee-Hwa Tai
- Deparment of Biochemistry, Microbiology, and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Abhirami A Ananth
- Deparment of Biochemistry, Microbiology, and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Center for Innovative Cancer Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Rashmi Seth
- Department of Surgery, Division of General Surgery, University of Ottawa, Ottawa, Canada
| | - Almohanad Alkayyal
- Deparment of Biochemistry, Microbiology, and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Center for Innovative Cancer Research, Ottawa Hospital Research Institute, Ottawa, Canada.,Department of Medical Laboratory Technology, University of Tabuk, Tabuk, Saudi Arabia
| | - Jiqing Zhang
- Center for Innovative Cancer Research, Ottawa Hospital Research Institute, Ottawa, Canada.,Department of Neurosurgery, The Second Hospital of Shandong University, Shandong, China.,Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | | | - Phillip Staibano
- Center for Innovative Cancer Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Michael A Kennedy
- Center for Innovative Cancer Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Rebecca C Auer
- Deparment of Biochemistry, Microbiology, and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Canada. .,Center for Innovative Cancer Research, Ottawa Hospital Research Institute, Ottawa, Canada. .,Department of Surgery, Division of General Surgery, University of Ottawa, Ottawa, Canada. .,Ottawa General Hospital, 501 Smyth Road, 1617 CCW, Box 134, Ottawa, ON, K1H8L6, Canada.
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