Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Abstract P5-14-12: Long-term outcome of HER2-normal early stage breast cancer (ESBC) patients (Pts) treated with docetaxel-cyclophosphamide (TC) chemotherapy (CTx): Mature results of a single-institution experience

BACKGROUND

Anthracycline(A)-containing regimens (AReg) became an established standard (neo)adj CTx for ESBC following fairly consistent demonstration of a modest superiority over older anti-metabolite/alkylating CTx. However, substantial translational data and a recently presented pooled analysis [Blum, 2016] suggest that this superiority could be largely driven by greater benefits in specific ESBC subgroups, i.e. HER2-altered BrCa (due to co-amplification of topoisomerase 2 and HER2), and triple-negative BrCa (TNBC). A are cardiotoxic (including late onset of cardiomyopathic congestive heart failure) and potentially leukaemogenic. In late 2006, following the results of the first USONC randomized clinical trial that showed superior outcomes of the non-AReg TC (docetaxel/cyclo­phosphamide) over AC, we established a routine, uniform policy of TC for all Pts receiving (neo)adj CTx for HER2-normal ESBC. We report the mature follow up of this single-institution unselected experience.

METHODS

We performed a retrospective outcome analysis of all Pts who received at least 1 cycle of (neo)adj TC (docetaxel 75 mg/m2 + cyclophosphamide 600 mg/m2 IV every 3 weeks) at our Department for HER2-normal ESBC and with at least 5 years of follow up (FU). Pts were identified by systematic analysis of the dataset of the Oncology Pharmacy Unit. Information on tumour characteristics [e.g. axillary lymph nodes (N) metastases, hormonal receptors (HR) and HER2 status] and Pts FU were retrieved and collected into an ad hoc designed database. Pts with node-positive (N+) ESBC received TC×6 cycles, and Pts with high-risk node-negative (N−) [e.g. primary tumour (T) &gt;2 cm, or HRneg, or T &gt;3 cm] ESBC received TC×4 cycles. Pts received adjuvant hormone therapy and radiotherapy as per standard of care. From 2008 on, many lower risk HR+/N− Pts were not given CTx due to OncotypeDx availability.

RESULTS

Between September 2006 and December 2015, 810 female HER2-normal ESBC Pts were treated with (neo)adj TC. In the final outcome analysis we included 464 Pts treated before June 2011 thus having a minimum FU of 5 years. Pts characteristics are: median age 53 yrs (range 30-77), N− 246 (53%), N+ 218 (47%), hormone receptors positive (HR+) 391 (84%), TNBC 73 (16%). The database was locked as of June 1st 2016. Median FU from first cycle of TC is 7.5 yrs (range 5.3-10). 63 BrCa-specific relapse events (defined as time to local, regional or distant recurrence, invasive contralateral breast cancer, excluding non-breast second primaries) have been observed, accounting for an overall Relapse-Free Survival (RFS) rate of 86.4%. 42 deaths have occurred, 36 (86%) due to BrCa, accounting for an Overall Survival (OS) rate of 91%. RFS and OS rates for the different Pts subgroups are reported in Table 1

Table 1 - Outcome parameters RFS (%)OS (%)All Pts8691HR+/N-9396HR+/N+8190TN/N-9191TN/N+5858

CONCLUSIONS

These mature data with long FU suggest that the outcome for a large cohort of unselected Pts with HER2-normal HR+ ESBC (regardless of nodal status) and for TN/N− ESBrCa treated with nonAReg TC is excellent. However, N+TN ESBrCa in this setting remains a significant clinical challenge.

Citation Format: Losurdo A, Gullo G, Buckley C, Lowry C, Ballot J, Silva N, Hammond L, Crown J. Long-term outcome of HER2-normal early stage breast cancer (ESBC) patients (Pts) treated with docetaxel-cyclophosphamide (TC) chemotherapy (CTx): Mature results of a single-institution experience [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-14-12.

A cluster randomised controlled trial of a web based decision aid to support parents' decisions about their child's Measles Mumps and Rubella (MMR) vaccination

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The use of decision aids for immunisation decisions is under researched and controversial.

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Parents receiving a decision aid or a leaflet had reduced decisional conflict for the MMR decision.

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MMR uptake in the decision aid and control arms achieved levels required for population immunity.

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Leaflet arm parents were less likely to vaccinate their child.

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Childhood immunisation decision aids can achieve both informed decision-making and uptake.

Objective

To evaluate the effectiveness of a web based decision aid versus a leaflet versus, usual practice in reducing parents’ decisional conflict for the first dose MMR vaccination decision. The, impact on MMR vaccine uptake was also explored.

Design

Three-arm cluster randomised controlled trial. Setting: Fifty GP practices in the north of, England. Participants: 220 first time parents making a first dose MMR decision. Interventions: Web, based MMR decision aid plus usual practice, MMR leaflet plus usual practice versus usual practice only, (control). Main outcome measures: Decisional conflict was the primary outcome and used as the, measure of parents’ levels of informed decision-making. MMR uptake was a secondary outcome.

Results

Decisional conflict decreased post-intervention for both intervention arms to a level where, parents could make an informed MMR decision (decision aid: effect estimate = 1.09, 95% CI −1.36 to −0.82; information leaflet: effect estimate = −0.67, 95% CI −0.88 to −0.46). Trial arm was significantly, associated (p < 0.001) with decisional conflict at post-intervention. Vaccination uptake was 100%, 91%, and 99% in the decision aid, leaflet and control arms, respectively (χ² (1, N = 203) = 8.69; p = 0.017). Post-hoc tests revealed a statistically significant difference in uptake between the information leaflet, and the usual practice arms (p = 0.04), and a near statistically significant difference between the, decision aid and leaflet arms (p = 0.05).

Conclusions

Parents’ decisional conflict was reduced in both, the decision aid and leaflet arms. The decision aid also prompted parents to act upon that decision and, vaccinate their child. Achieving both outcomes is fundamental to the integration of immunisation, decision aids within routine practice. Trial registration: ISRCTN72521372.

A novel HLA-B*40 sequence--B*40:92

A new allele, HLA-B*40:92, was identified in a north-western European subject during polymerase chain reaction using sequence-specific priming (PCR-SSP)-based typing of haematopoietic stem cell (HSC) donors. B*40:92 differs from B*40:01:01 by six nucleotides at positions 559, 560, 603, 605, 610 and 618 in exon 3 which represents a substitution motif of at least 60 nucleotides. This motif, which occurs in numerous HLA alleles including the relatively high frequency B*15 and B*35 allele families, encode four amino acid changes at positions 163 (glutamic acid > leucine), 177 (aspartic acid > glutamic acid), 178 (lysine > threonine), 180 (glutamic acid > glutamine) and a silent substitution, conserved alanine, at codon 182. Thus, it is likely that HLA-B*40:92 occurred following a gene conversion-like or interallelic recombination event involving B*40:01:01 and probably a B*15 or more likely a B*35 family allele. HLA-B*40:92 was found on a haplotype with HLA-A*02:01, B*40:92, C*03:04, DRB1*13:02, DRB3*03:01, DQA1*01:02, DQB1*06:04, DPA1*02:02, DPB1*05:01. Tests on 69 selected B40 and B35 antisera and Lambda Monoclonal Trays™ show that B*40:92 encodes a 'short' B40/B60 serological specificity which displays some HLA-B35 reactivity. The HLA-B40 and HLA-B35 motifs (possible epitopes) responsible for this serological reactivity were identified. This single example of HLA- B*40:92 was found in 56,823 consecutive HLA PCR-SSP typed HSC donors indicating a carriage frequency of 0.00176% (allele frequency 0.00001) in blood donors resident in Wales. An Epstein-Barr virus transformed B-cell line from the HLA-B*40:92 donor is available.

A new HLA-C allele: Cw*0819

Human leucocyte antigen-Cw*0819 differs from Cw*0802 by two nucleotides resulting in an amino acid change of 99tyrosine to 99phenylalanine and a synonymous substitution.

A new HLA-B*08 variant--B*0838

HLA-B*0838 differs from B*080101 by three nucleotides resulting in an amino acid change of 63asparagine to 63glutamic acid and a synonymous substitution.

Two new HLA-C alleles: Cw*0222 and Cw*0434

HLA-Cw*0222 differs from Cw*020202 by three nucleotides at codons 114, 116 and 127, while HLA-Cw*0434 differs from Cw*0408 by two nucleotides at codons 152 and 156.

A new HLA-A*02 null allele, HLA-A*9213N

A novel HLA-A*02 null allele, differing from HLA-A*02010101 at codon 60 (TGG tryptophan-->TAG stop), is described.

A novel HLA-B*44 allele, HLA-B*4459, identified in a renal patient with aberrant B44 serology and characterized by sequence-based typing

Human leukocyte antigen-B*4459 was first identified in a renal patient. The novel allele differs from B*44020101 by a single nucleotide change in exon 3 at nucleotide 453 (C-->G), which changes codon 127 from asparagine (AAC) to lysine (AAG) explaining some aberrant B44 serology results in 2003.

A new HLA-B*15 variant - B*9507

The human leukocyte antigen-B*15 variant B*9507 is similar to B*1505 (B62) but with substitutions of A>C at position 463 and G>C at position 477 in exon 3. This results in a single amino acid change of serine to arginine (AGC>CGC) at codon 131 and a silent substitution (GCG>GCC - conserved alanine) at codon 135.

Identification of a variant HLA-A*3401 allele, A*340102, in an educational DNA typing sample

A*340102 was first identified in an ASEATTA Educational DNA typing sample, which typed as A*3401, 3401variant. The variant differs from A*3401 by a single silent substitution in exon 2 at nucleotide 309, codon 79 (GGG-->GGT).

A high-resolution polymerase chain reaction-sequence-specific primer HLA-B*27 typing set and its application in routine HLA-B27 testing

We designed a set of 35 polymerase chain reaction sequence-specific primers (PCR-SSP) in 29 SSP mixtures to assign 29 HLA-B*27 4-digit level alleles (B*2701-B*2721 and B*2723-B*2730). This was used in conjunction with our 41 PCR-SSP primer mixture low-resolution HLA-B typing set to fully differentiate B*27 from all other HLA-B alleles. Successful typing set validation used 521 B*27 samples covering 13 (B*2701-B*2710 and B*2712, B*2717, B*2723) alleles. The distribution of B*27 alleles was determined in a random population of 4020 local blood donors and the use of PCR-SSP B*27 typing in our routine flow cytometry-based HLA-B27/B2708 typing strategy is described.

Identification of a novel HLA-A allele (A*1115) in the UK National External Quality Assessment Schemes for Histocompatibility and Immunogenetics' Educational Cell Exchange

The novel allele, HLA-A*1115, was identified in an 'Educational Scheme' sample (ED03/03 - from a north-western European Caucasoid blood donor) distributed by the UK National External Quality Assessment Schemes for Histocompatibility and Immunogenetics. ED03/03 was typed by serology, the polymerase chain reaction using sequence-specific primers and sequence-based typing. A*1115 is most similar to A*110101 with a single mismatch (G to C) at constant position 565, leading to a conservative amino acid change from valine (GTG) to leucine (CTG) at codon 165 in the alpha(2) domain. This substitution has not been reported for any other HLA class I allele so far. The HLA-A*1115-bearing haplotype was B*350101; Cw*040101; DRB1*140101; DRB3*020201; DQA1*010401; DQB1*0503; DPA1*0103/07; DPB1*030101. Extensive serological typing indicated that this allele essentially encodes a 'normal' HLA-A11 specificity.

Immunogenetics of a new HLA-B null allele, HLA-B*4423N

The second example of an HLA-B*44 null allele (B*4423N) was identified by discrepancies between serological and polymerase chain reaction-sequence-specific primer (PCR-SSP) typing in two north-western European Caucasoid unrelated stem cell donor volunteers. HLA-B*4423N was identical to B*440201 except for a single nucleotide substitution at position 493 in exon 3, resulting in a premature stop codon at bases 493-495 (TAG rather than CAG at codon 141). As expected, comprehensive serological testing using 54 antisera, directed towards B44 or Bw4, failed to identify the HLA-B44 (Bw4) specificity. The B*4423N-bearing haplotype was identified as A*0201, Cw*0501, DRB1*0408, DRB4*01, DQA1*03, DQB1*0304 and the frequency of B*4423N estimated as 0.00006 (carriage frequency 0.0121%) in 16 533 subjects resident in Wales.

Observations on the HLA-A2403 specificity

We found HLA-A*2423 in a subject possessing the HLA-A2403 specificity. Consequently we delineated the A*24 alleles of 41 subjects previously assigned as 'A2403' by serology and/or 'low-resolution' PCR-SSP (allele group: A*2403/10/18/22/23/33) and found that 36 were A*2403, 3 were A*2410 and 2 were A*2433. The A*2410 and A*2433 subjects also typed as A2403. Several likely A*2410/23/33-bearing haplotypes were identified and the frequency of the A*2403/10/18/22/23/33 alleles was determined in 26,826 Welsh blood donors. We suggest that HLA-A9/A24 antibodies against epitope(s) involving 166D and 167G will fail to react with all A*2403/10/18/22/23/33 products. As it is this 'short' A9/A24 serological reactivity that defines HLA-A2403 all these products will be serologically designated as HLA-A2403.

Immunogenetics of two new HLA alleles: A*0108 and B*4031

Two new alleles, HLA-A*0108 and B*4031, were identified in north-western European Caucasoid subjects. A*0108 differed from A*010101 by a single substitution (C to T) at position 216 in exon 3, resulting in an amino acid difference of Arg to Trp at position 163. It was present on a haplotype with B*1501/60/70/71; Cw*0303; DRB1*1301; DRB3*0202; DQA1*0103; DQB1*0603 and its product reacted as a normal HLA-A1 specificity. B*4031 differed from B*4001 by two nucleotides in exon 3 (positions 20 (G to C) and 69 (A to G)) resulting in two amino acid differences (Arg to Ser at position 97 and Asn to Asp at position 114). It was found on a haplotype with HLA-A*03; Cw*0304; DRB1*0404/32; DRB4*0101/3/5; DQA1*03; DQB1*0302 and has the HLA-B60 specificity. Both alleles have frequencies of < 0.0002 in the largely north-western European Caucasoid blood donor population resident in Wales.

Immunogenetic study of a new HLA allele, B*2723

A novel HLA-B*27 allele (B*2723) detected by irregular serological and PCR-SSP typing results was identified by nucleotide sequencing of exons 2 and 3. B*2723 differs from B*27052 by nine nucleotides which encode seven amino acid changes at positions 63 (Glu to Asn), 67 (Cys to Phe), 69 (Ala to Thr), 70 (Lys to Asn), 71 (Ala to Thr), 74 (Asp to Tyr) and 77 (Asp to Ser) in the alpha1 helix. All these substitutions are possessed by B*35 alleles suggesting that B*2723 was created by a gene conversion-like event involving B*27052 and a B*35 allele. Using the HLA-A*26 and DRB1*12 alleles of the B*2723-bearing haplotype as 'markers', two further examples of B*2723 were found in 29,851 blood donors. Therefore, B*2723 has a 'minimum' gene frequency of 0.000034 (phenotype frequency 0.0067%) in blood donors resident in Wales. In all three families, B*2723 was present on a haplotype with: A*26; Cw*0202; DRB1*1201/6/7; DRB3*02; DQA1*05; DQB1*0301. The B*2723 product failed to react with HLA-B27 antisera and reacted weakly or not at all with Bw4 antisera. Lack of the ECAKA motif at amino acid positions 63, 67, 69-71 probably accounts for lack of the B27 specificity while the amino acid combination 74Y, 77S, 80T, 81L may cause aberrant Bw4 reactivity.

Phase I and pharmacokinetic study of NSC 655649, a rebeccamycin analog with topoisomerase inhibitory properties

PURPOSE

To assess the feasibility of administering NSC 655649, a water-soluble, rebeccamycin analog with topoisomerase inhibitory properties, as a brief intravenous (IV) infusion once every 3 weeks and to determine the maximum-tolerated dose (MTD) of NSC 655649, characterize its pharmacokinetic behavior, and seek preliminary evidence of antitumor activity.

PATIENTS AND METHODS

Patients with advanced solid malignancies were treated with escalating doses of NSC 655649 administered over 30 to 60 minutes IV once every 3 weeks. An accelerated dose-escalation method was used to guide dose escalation. After three patients were treated at the first dose level, doses were escalated in increments that ranged up to 150% using single patient cohorts until moderate toxicity was observed, when a more conservative dose-escalation scheme was invoked. MTD was defined as the highest dose level at which the incidence of dose-limiting toxicity did not exceed 20%. MTD was determined for both minimally pretreated (MP) and heavily pretreated (HP) patients. Plasma and urine were sampled to characterize the pharmacokinetic and excretory behavior of NSC 655649.

RESULTS

Forty-five patients were treated with 130 courses of NSC 655649 at doses ranging from 20 mg/m(2) to 744 mg/m(2). Myelosuppression was the principal toxicity. Severe neutropenia, which was often associated with thrombocytopenia, was unacceptably high in HP and MP patients treated at 572 mg/m(2) and 744 mg/m(2), respectively. Nausea, vomiting, and diarrhea were common but rarely severe. The pharmacokinetics of NSC 655649 were dose dependent and fit a three-compartment model. The clearance and terminal elimination half-lives for NSC 655649 averaged 7.57 (SD = 4.2) L/h/m(2) and 48.85 (SD = 23.65) hours, respectively. Despite a heterogeneous population of MP and HP patients, the magnitude of drug exposure correlated well with the severity of myelosuppression. Antitumor activity was observed in two HP ovarian cancer patients and one patient with a soft tissue sarcoma refractory to etoposide and doxorubicin.

CONCLUSION

Recommended phase II doses are 500 mg/m(2) and 572 mg/m(2) IV once every 3 weeks for HP and MP patients, respectively. The absence of severe nonhematologic toxicities, the encouraging antitumor activity in HP patients, and the unique mechanism of antineoplastic activity of NSC 655649 warrant further clinical development.