One size does not fit all: community views on choices for TB treatment and prevention

Treatment and prevention paradigms in TB have been dominated by a 'one-size-fits-all' approach, in which all persons are given the same treatment regimens. This stands in contrast to other health conditions, where differentiated models of care have been shown to be effective. In this Viewpoint, we make the case for considering multiple factors when deciding which regimens should be offered to people with TB infection and disease. Choice about which regimens to use should be made in conjunction with people who have TB and consider efficacy, safety, duration, pill burden, formulation, drug interactions, time spent in monitoring, drug susceptibility, compatibility with other areas of life, and availability of support services. Ideally, these choices should be considered within an equity framework with the most intensified services being offered to those considered most vulnerable.

Diagnostic accuracy of amyloid scintigraphy for the histopathological diagnosis of cardiac transthyretin amyloidosis – a retrospective Austrian multicenter study

Background

Previous studies indicated that amyloid scintigraphy in combination with free light chain (FLC) assessment yields an excellent diagnostic accuracy for cardiac transthyretin (ATTR) amyloidosis (1). As a consequence, the diagnosis of ATTR amyloidosis is increasingly made without the actual gold-standard method endomyocardial biopsy (EMB). Whether this leads to misdiagnosis in real-world practice is currently underinvestigated. We aimed to describe the diagnostic accuracy of amyloid scintigraphy in a real world setting.

Methods

Seven tertiary care centers throughout Austria agreed to participate in the study and performed a systematic retrospective medical records search from 2017 to 2020. Patients were included in case of available results of amyloid scintigraphy, FLC assessment and EMB, respectively. Amyloid scintigraphy was performed using a 99m-technetium-labelled tracer. Histological analysis was performed using immunohistochemistry. The number of submitted subjects with complete data per center ranged from 2 to 46. The patient number increased with years, with 15 patients investigated in 2017 and 32 in 2020.

Results

We enrolled 101 patients (21% women) with a mean age of 73±9 years and median NT-proBNP (IQR) of 2694 (1601–5239) pg/ml (Table 1). An abnormal Perugini Score (ie. grade II or III) was present in 57 patients (56%) and FLC assessment was overall indicative of monoclonal protein in 60 patients (59%). Among patients with abnormal Perugini Score, 29 had FLC assessment indicative of monoclonal protein. The most common histopathological diagnoses were ATTR in 60 patients (59%) and cardiac light chain (AL) amyloidosis in 20 patients (20%). One further patient was diagnosed with concomitant AL and ATTR amyloidosis. Further diagnoses included ApoA4 (n=2) and AA amyloidosis (n=1), while cardiac amyloidosis was ruled out in 17 patients (17%).

ATTR was diagnosed in 54 patients with Perugini Score II or III compared with 6 patients with Perugini < II, yielding a sensitivity of abnormal Perugini score for ATTR amyloidosis of 90%. Among patients with abnormal Perugini Score (n=57), ATTR was diagnosed in 55 patients, and AL amyloidosis in 3 (one had concomitant ATTR and AL), yielding a positive predictive value (PPV) of abnormal Perugini Score of 97% (Table 2). Two AL patients had Perugini Score of II and one had Perugini Score of III. When excluding patients with monoclonal gammopathy, the PPV of abnormal Perugini Score was 100%.

Conclusion

Our data confirm a PPV of abnormal amyloid scintigraphy of 100% for cardiac ATTR amyloidosis when monoclonal gammopathy was excluded. mong patients with monoclonal gammopathy, one of ten patients with abnormal scintigraphy had AL amyloidosis as the underlying condition. Our data underscore that tissue biopsy and histopathological analysis should be performed in every patient with suspected amyloidosis and monoclonal gammopathy even in case of Perugini Score II or III.

Funding Acknowledgement

Type of funding sources: None.

Outcome of transcutaneous edge-to-edge mitral valve repair in patients with diabetes mellitus: results from a real-world cohort

Background

Transcutaneous edge-to-edge repair (TEER) has become a treatment option for selected patients with severe mitral regurgitation (MR). Analysis of the COAPT trial indicated patients with diabetes mellitus to have higher death rates and a trend to higher rates of heart failure hospitalization (HFH) than those without diabetes. However, in that study only patients with secondary MR with specific criteria were included and there are only limited data on diabetes patients in real-world settings.

Purpose

This study sought to evaluate safety and efficacy of TEER in patients with diabetes mellitus in comparison to non-diabetics.

Methods

In this monocentric study 340 consecutive patients with severe primary and secondary MR who underwent TEER were included. Immediate results of the procedure, intrahospital as well as one-year outcome were compared between patients with and without diabetes.

Results

Diabetes was present in 109 patients (32%) of the study group. Patients with diabetes were younger (75±8 vs. 78±8 years; p=0.003), had more often ischemic cardiomyopathy (68% vs. 48%, p<0.001), previous coronary-artery bypass graft (35% vs. 20%; p=0.002) and arterial hypertension (89% vs. 75%; p<0.001) compared to those without diabetes. All other baseline clinical and imaging characteristics including NYHA class, left ventricular dimensions and function (ejection fraction: 38±13% vs. 41±14%; p=0.10) as well as severity of MR were not different between both patient groups (Table 1).

Success of the procedure was comparable between patients with and without diabetes (95% vs. 95%; p=0.84). There was no difference in intrahospital mortality between both groups (5.5% vs. 4.8%; p=0.98). At one-year follow up, there was no difference regarding all-cause mortality (24.2% vs. 23.0%; p=0.72), HFH (37.4% vs. 31.0%, p=0.23), NYHA class (p=0.11) or MR severity (p=0.20) between both groups (Table 2).

Conclusion

In contrast to previous published data on patients with diabetes and severe MR TEER seems to be similar safe and effective in a real-world setting compared to non-diabetics.

Funding Acknowledgement

Type of funding sources: None.

Implementation of a “genetic testing station” in a safety net hospital to optimize access and increase equity

e18565

Background: Diagnosis of hereditary cancers by genetic testing (GT) has significant implications for treatment decisions for individuals and risk reduction among family members. Recent guidelines have expanded the eligibility criteria for GT. However, significant disparities in GT completion persist based on race, ethnicity, insurance status, and English proficiency. Thus, novel interventions are needed to provide diverse populations equitable access to GT. Methods: From March to October 2021, we conducted a single arm study of a genetic testing station (GTS) intervention in a safety net hospital. The GTS intervention included (1) screening of clinic schedules for eligible patients; (2) video-based GT education in English, Spanish, and Cantonese; (3) consent for GT and collection of a blood or saliva sample by a genetic counseling assistant; (4) telehealth-based post-test counseling with a genetic counselor (GC). Bilingual, culturally concordant staff developed the educational videos and study materials. Patients who met the NCCN criteria for GT were eligible. We compared this group to a historical cohort who initiated GT in the preceding nine months. The historical cohort underwent GT in a traditional model: (1) oncologist-initiated referral, (2) pretest counseling with a GC, (3) GT if appropriate, and (4) post-test counseling to review and discuss results. Our primary outcomes were accessibility and feasibility assessed by tracking the implementation process. Secondary outcomes included completion rates of GT and post-test GC visit, and time from enrollment to GT result disclosure. We evaluated all associations with Chi-square tests for categorical variables and Pearson’s Chi-square test of medians for time to post-test visit. Results: We approached 92 patients for GTS; 3 declined, 89 patients underwent the GTS intervention. Of 155 patients (GTS: n = 89, historical cohort: n = 66), 15% were Black, 28% Asian, 17% White, 31% Hispanic/Latinx, 2% Native Hawaiian/Pacific Islander, and 7% multiethnic/other; 51% spoke English, 27% Spanish, 17% Cantonese, and 5% other. In the GTS cohort, 85 (96%) of participants completed GT and 80 (90%) completed the post-test GC visit, compared to 46 (70%, p < 0.001) and 42 (64%, p < 0.001) respectively in the historical cohort. The median time to result disclosure was 30.5 days (IQR 23.8 - 38.8) for the GTS cohort and 80.5 days (IQR 37.5 - 137.5, p = 0.001) for the historical cohort. Conclusions: Implementation of GTS was feasible and acceptable in a safety net setting. GTS resulted in more patients completing GT and post-test counseling and significantly reduced the time to result disclosure, which has the potential to impact treatment decisions and outcomes. As GT eligibility criteria broaden, innovative interventions, workflows, and tailored educational resources for diverse populations are needed to ensure equitable access to GT.

3D cardiac magnetic resonance stress-perfusion in elderly patients

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Swiss National Science Foundation

Introduction

Age related comorbidities and reduced compliance often limit ischaemia testing in elderly patients.

Purpose

To assessed the accuracy of 3D cardiac magnetic resonance (CMR) stress perfusion in the elderly population.

Methods

56 patients aged ≥75 years underwent 3D CMR stress-perfusion and invasive coronary angiography with quantitative coronary angiography (QCA) and fractional flow reserve (FFR) as part of a multicenter study. The accuracy of 3D CMR stress-perfusion was compared to patients aged &lt;75 years old (n = 360) using qualitative and quantitative imaging parameters.

Results

Sensitivity, specificity, positive and negative predictive values of qualitative 3D perfusion CMR were similar for both age groups in the detection of high-grade (≥50%) coronary stenosis on QCA and hemodynamically relevant (&lt;0.8) stenosis on FFR, p &gt; 0.05 all. Quantitative myocardial ischemia burden was larger in elderly patients (15% ± 17% vs. 9% ± 13%) with similarly high diagnostic accuracy of quantitative 3D CMR perfusion in both age groups to predict pathological FFR (AUC ≥75: 0.906; AUC &lt;75: 0.866).

Conclusions

3D CMR perfusion is well suited for myocardial ischaemia testing in the elderly patients with similarly high diagnostic accuracy as in younger individuals.

WHO ethics guidance on TB care and migration: challenges to the implementation process

We summarise the current ethical guidance on tuberculosis (TB) care and migration, as set out in the WHO "Ethics Guidance for the Implementation of the End TB Strategy." Among other aspects, the Ethics Guidance states that there should be firm legal principles in place that ensure the enforcement of migration law on the one hand and the protection of human rights, including the right to health, on the other are separated from one another. As a challenge to the Ethics Guidance and its implementation, we describe two cases, each of which typifies particular problems. Case one describes the experience of a migrant worker in the United Arab Emirates who is deported when mandatory medical exams show evidence of current or prior TB. Case two raises the issue of providing more than TB care, which may also be needed for holistic care. The paper concludes with our suggestions for ways in which we could make progress towards ethically optimal TB care for migrants.

Abstract PO-012: Acceptance and refusal among multi-lingual safety net patients to participate in a trial comparing genetic counseling delivery modes

Introduction While still low, diversity among clinical trial participants has improved in recent years due to efforts to eliminate health disparities. Here we present and endeavor to explain participation rates in our multicenter partially randomized preference noninferiority trial comparing the effectiveness of phone, video, and in person genetic counseling among high-risk English-, Spanish-, and Chinese-speaking patients. Methods High-risk patients were identified using a family history screener in clinics and via physician referrals. After reviewing forms received, bilingual/bicultural clinical research coordinators (CRC) called patients considered eligible in their preferred language (English, Spanish or Cantonese, Mandarin or Toisanese). Patients were informed that their hospital was conducting the study in conjunction with an academic institution. The CRC went over each patient’s family history of cancer to confirm eligibility and to explain the study components, including free genetic counseling. Because previous research had significant refusals due to patients’ preferences for a single mode, our consented patients were asked if they would accept random assignment to phone, video, or in person counseling or if they had a strong preference. Patients who declined were asked their reasons. Results Out of 1,403 patients reached (70% English-, 26% Spanish-, and 3% Chinese- speaking), 86% agreed to participate. The highest acceptance rate was among Spanish-speakers (94%), followed by English-speakers (83%) and Chinese-speakers (67%). Among the 201 patients who declined, 49% did so upon contact, while 51% declined after eligibility was confirmed. Reasons for declining are available for 71% of decliners as follows: 22% not interested; 19% no time; 10% cited no benefit them or family members; 7% did not want to talk about cancer; 7% had too many other medical issues; and 6% provided a range of other reasons. Discussion and Conclusions We believe that our study’s high initial participation rate for patients contacted was due to the purpose which was particularly meaningful to those with a family history of cancer. Also, patients trusted their own hospitals which co- sponsored the study. It was helpful that providers in the 3 public hospitals strongly supported the research which provided much needed genetic counseling and pursued questions important to access to genetic services. Importantly, our study design addressed significant known barriers to minority and low SES participation in clinical trials through the use of bilingual/bicultural investigators, multi-language study materials, and strong, positive working relationships with gatekeeper medical and clinic support staff. Reasons given for declining may indicate the existence of a socio-economic structural ceiling for participation due to patient vulnerabilities and societal burdens, causes outside the investigative scope of our study that are likely to continue to hamper efforts to improve participation if not addressed.

Citation Format: Robin Lee, Miya Frick, Celia Kaplan, Galen Joseph, Janice Tsoh, Selina Flores, Niharika Dixit, Heather Cedermaz, Lly Wang, Amal Khoury, Brittany Campbell, Rena Pasick, Claudia S. Guerra, Susan L. Stewart. Acceptance and refusal among multi-lingual safety net patients to participate in a trial comparing genetic counseling delivery modes [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-012.

Abstract PO-051: Genetic counseling for high-risk public hospital patients: A randomized and preference-based trial compares delivery in person, by phone, and video

In public health settings, where availability of genetic counseling (GC) and testing for hereditary breast and ovarian cancer is limited, telehealth could expand access to academic centers where these services are concentrated. However, little is known about the effectiveness of remote modes for ethnically diverse and low health literacy patients. Methods. From 2017-20 UCSF researchers partnered with 3 public hospitals to conduct a partially randomized preference noninferiority trial with English-, Spanish-, and Cantonese-speaking patients with strong personal and/or family history of cancer. Participants received GC in person, by phone, or via video. Pre- and post-GC telephone surveys measured study outcomes: knowledge, cancer- specific distress, decisional conflict, risk perception, and satisfaction. A subset of 23 participants was recruited for case studies (CS) to elucidate quantitative findings. CS integrated patient and counselor in-depth interviews, GC session transcripts, and survey and tracking data for a multi-dimensional understanding of each individual’s GC experience. Results. Among 23,633 family history forms collected, 1,574 patients were eligible; 1404 were reached and 708 consented. Of 394 randomized, 322 attended GC and 312 completed the final survey. After GC, mean knowledge scores increased, and cancer-specific distress and decisional conflict decreased overall.

Counseling attendance varied significantly by assigned mode (75% via video at a clinic, 77% in person, and 92% by phone), but the modes yielded noninferior outcomes. Respondents overwhelmingly rated all modes as “very convenient” and satisfaction with counseling as “very high.” Compared with baseline, knowledge increased significantly regardless of mode. However, this increase was significantly less for African Americans and for those with less education (with each adjusted for the other) across all modes. Completion of genetic testing (GT) was the inverse of counseling attendance: 94% in person, 93% video, and 65% by phone. Case studies (CS) revealed the complexities of counseling public hospital patients. Phone patients valued the access despite connection issues, but phone appointments tended to be briefer, and qualitative interviews suggested that communication was less effective by phone. While many phone patients said they would not be able to access GC any other way, several felt they would get more out it in person. Importantly, GT was offered on the spot to in-person patients while some counseled by phone had second thoughts and other barriers. CS of video counseling found benefits similar to in-person GC such as use of visual cues and formation of meaningful connections. Conclusion. Our findings indicate that GC can be delivered to high-risk public hospital patients remotely by phone, video, or in-person in order to fill a gap in access to critical genetic services. Further research is needed to achieve optimal outcomes for all patients and to increase the rate of testing for those counseled by phone.

Citation Format: Rena J Pasick, Susan L. Stewart, Robin Lee, Claudia Guerra, Celia Kaplan, Galen Joseph, Selina Flores, Janice Tsoh, Niharika Dixit, Miya Frick, Heather Cedermaz, Lily Wong, Amal Khoury, Brittany Campbell. Genetic counseling for high-risk public hospital patients: A randomized and preference-based trial compares delivery in person, by phone, and video [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-051.

High sensitive troponin T as gatekeeper for cardiac magnetic resonance imaging in patients with suspected acute myocarditis

Background

The diagnosis of acute (AM) is difficult because of the variable, unspecific clinical presentation. Cardiac magnetic resonance (CMR) is the noninvasive gold standard diagnostic tool, but limited availability and high costs make a quick and inexpensive test necessary to clarify the need for CMR. Quantification of high sensitive Troponin T (hsTNT) is a broadly available, specific blood test for cardiomyocyte damage.

Aim

The aim of this study was to evaluate hsTNT as a gatekeeper for CMR with a lower cut off-value for exclusion and an upper cut-off value for confirmation of acute myocarditis as defined by CMR.

Methods

This retrospective analysis included 244 patients (age 39±17 years, 71% male) who received CMR for clinically suspected AM and quantification of hsTNT within 28 days (Median: 2 days) of CMR. CMR (1.5 Tesla) consisted of cine-sequences, edema-sensitive T2 and late gadolinium enhancement (LGE) imaging. AM was diagnosed in presence of both, myocardial edema and LGE consistent with acute myocarditis.

Results

Of 244 patients, 78 (32%) were CMR-positive (CMR+) for AM. 166 (68%) were CMR negative (CMR−). Mean hsTNT was 206±454 pg/ml.

HsTNT was significantly higher in CMR+ than in CMR− (604±639 pg/ml vs 20±56 pg/ml, p&lt;0.001, see figure A). 8 CMR+ patients (10%) had hsTNT in the normal range (&lt;14 ng/ml).

HsTNT showed good discriminatory performance in the Receiver Operator Characteristic (ROC) analysis (AUC 0.91, see figure B).

A lower cut-off value of 4 pg/ml had a sensitivity of 98.7% for diagnosis of AM (hsTNT ≥4 pg/ml) and a negative predictive value of 98.2% for rule out of AM (hsTNT&lt;4 pg/ml) as defined by CMR, leading to a reduction of 23.4% of CMR exams. An upper cut-off value of &gt;343 pg/ml had a specificity of 99.4% and positive predictive value of 97.8% for diagnosis of AM, leading to a reduction of 18.4% of CMR exams (see table).

Conclusions

hsTNT showed good discriminatory capacity for acute myocarditis (AM) as defined by CMR. However, 10% of patients had hsTNT in the normal range (&lt;14 pg/ml). A lower cut-off value of &lt;4 pg/ml ruled out AM with very high negative predictive value, whereas an upper cut-off of &gt;343 pg/ml had a very high positive predictive value for confirmation of AM as defined by CMR. Performing CMR only in patients with hsTNT between 4 and 343 pg/ml would have led to a reduction of 41.8% of CMR exams.

Funding Acknowledgement

Type of funding source: None

Timing and degree of left atrial stunning and reverse functional remodeling following electrical cardioversion in patients with recent onset atrial fibrillation

Background

Atrial fibrillation (AF) results in left atrial electrical, structural and functional remodeling. Restoration of sinus rhythm hallmarks the beginning of reverse remodeling, the extent of which may depend on the type of AF.

Purpose

The aim of the study was to assess resumption of left atrial function after electric cardioversion in patients with recent onset AF and to explore the association between reverse remodeling and the type of atrial fibrillation.

Methods

Patients with AF duration &lt;48 hours were prospectively included. Trans-thoracic echocardiography was performed prior, immediately after (2–4 hours) and 7–10 days following CV. Left atrial volume index (LAVI), left atrial global longitudinal strain during reservoir (LAGLS-res), conduit (LAGLS-cond) and contractile (LAGLS-contr) phases, left atrial ejection fraction (LAEF) and left ventricular ejection fraction (LVEF) were measured.

Results

Forty-three patients (84% males) aged 55±9.6 years, (mean±SD), with median CHA2DS2-VASc score 1 (interquartile range 0–1) were included. Repeated measure analysis of variance revealed a statistically significant overall change for LAGLS-res F(2,78)=55.4, p&lt;0,001, LAGLS-cond F(2,78)=23.3, p&lt;0,001, LAGLS-contr F(2,78)=39.7, p&lt;0,001, LAEF F(2,80)=28.5, p&lt;0.001 and LVEF F(2,80)=8.4, p&lt;0.001. At 7–10 days, LAGLS-contr 12±4%, LAEF 53±9% and LVEF 60±6 (mean±SD) return within normal reference intervals. Notably left atrial recovery seems to precede left ventricular recovery. No statistical significant interaction with the type of atrial fibrillation could be shown.

Conclusion

Left atrial functional reverse remodeling occurs within ten days after successful electric cardioversion of patients with recent onset atrial fibrillation.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swedish Heart-Lung Foundation, Correvio International Sárl (Geneva Switzerland), Selanders Stiftelse

Activation of inflammatory/coagulation system following electrical cardioversion of patient with recent onset atrial fibrillation: an explorative study of the relation to white matter hyperintensities

Background

White matter hyperintensities (WMH), assessed using Fazekas scale, are more prevalent in patients with atrial fibrillation (AF), although its pathophysiologic mechanism(s) is unclear.

Purpose

The study objective was to explore the association between cardiac, inflammatory and coagulation biomarkers and white matter hyperintensities in anticoagulant-naïve patients following electrical cardioversion (CV) of recent onset AF.

Methods

Patients with AF duration &lt;48 hours were prospectively included. Brain magnetic resonance imaging (MRI), C-reactive protein (CRP), high-sensitivity troponin T (hs-TNT), NT-proBNP, Interleukin 6, P-selectin, D-dimer, prothrombin fragment 1+2, von Willebrand factor Ag, coagulation factor VIII C and fibrinogen, were obtained sequentially prior, after (2–4 hours) and 7–10 days following CV. Repeated measure analysis of variance was performed.

Results

Forty-three patients (84% males), aged 55±9.6 years, (mean±SD) with median CHA2DS2-VASc score 1 (interquartile range 0–1) were included. Sequential MRI showed no new brain lesions after CV, while WMH were present at baseline in 21/43 (49%) patients. Repeated measure analysis of variance revealed a statistically significant overall change for hs-TNT: F(2,84)=6.056, p=0.03, NT-proBNP: F(2,84)=106.02, p&lt;0.001, P-selectin: F(2,84)=8.69, p&lt;0.001 and vWF:Ag: F(2,84)=4.078, p=0.02. CRP, IL-6, coagulation factor VIII-C and fibrinogen showed the same pattern, however none reached statistical significance. Patients with WMH had persistent higher values for CRP, hs-TNT, D-dimer, prothrombin fragment 1+2 and fibrinogen prior and after CV, as values at 7–10 days coincided; however, statistical interaction was not significant.

Conclusion

Transient activation of inflammatory and coagulation systems during atrial fibrillation subsides within 7–10 days after electric cardioversion of recent onset atrial fibrillation. A tendency of higher degree of activation during atrial fibrillation was observed in patients with white matter hyperintensities.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swedish Heart-Lung Foundation, Swedish Research Council, Correvio International Sárl (Geneva Switzerland), Selanders Stiftelse

Prasugrel compared to ticagrelor in primary PCI

Background

Prasugrel and ticagrelor have similar recommendations in the setting of primary PCI by current guidelines. Data comparing both in daily clinical practice of primary PCI for ST-elevation myocardial infarction is limited.

Purpose

To compare the effect of prasugrel and ticagrelor on in-hospital outcomes after primary PCI.

Methods and results

We prospectively enrolled 5365 patients treated with prasugrel (n=2785, 51.9%) or ticagrelor (n=2580; 48.1%) in the setting of primary PCI from January 2011 to December 2018 in a nationwide registry. In-hospital outcomes were compared and multiple logistic regression analysis was performed. Prasugrel treated patients were younger, less often in cardiogenic shock, with lower rates of previous stroke and had shorter ischemic time. Both groups showed similar rates of previous MI, diabetes and current resuscitation. In the univariate analysis mortality was lower in patients with prasugrel (2.5% vs. 4.4% p&lt;0.01). Similarly, MACE (3.3% vs. 5.3%, p&lt;0.01) and NACE (4.0% vs. 5.7% p&lt;0.01) were lower in prasugrel treated patients, whereas major bleeding events did not differ (0.4% vs. 0.6% p=0.24).

After adjustment in multivariable analysis mortality (0.99 95% CI 0.57 to 1.72), MACE (OR 0.99 95% CI 0.65 to 1.52) as well as NACE (0.86 95% CI 0.61 to 1.22) did not differ in patients treated with prasugrel compared to ticagrelor.

Conclusion

Patients treated with prasugrel showed improved outcomes compared to ticagrelor in a large cohort of primary PCI. However, after adjustment for confounders the Advantage of prasugrel in primary PCI did not persist.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Austrian Society of Cardiology

P1080Magnetic resonance imaging after electrical cardioversion of recent-onset atrial fibrillation in anticoagulant-naive patients - a study exploring clinically silent cerebral lesions

Funding Acknowledgements

Unrestricted grants from the Swedish Heart-Lung Foundation, the Swedish Research Council, Correvio International Sárl (CH) and Selanders stiftelse

Background

Patients with atrial fibrillation (AF) have a high incidence of cognitive impairment, which may be related to clinically silent microembolism causing cerebral infarctions.

Purpose

To explore the occurrence and timing of silent brain lesions following electrical cardioversion (CV) of recent onset AF in anticoagulant-naïve patients and to further study related effects on cognitive function and biomarkers of cerebral damage, S100b.

Methods

Patients with AF duration &lt; 48 hours were prospectively included. Brain magnetic resonance imaging (MRI) and S100b, were obtained prior, after and 7-10 days following CV. Trail making tests (TMT-A and TMT-B) and their difference, ΔΤΜΤ, were assessed prior to CV, 7-10 days and 30 days after CV.

Results

Forty-three patients (84% males) with mean CHA2DS2-VASc score 0.6 ± 0.7 were included. Sequential MRI, including diffusion weighted scans, showed no new brain lesions after CV.

Chronic white matter hyperintensities (WMH) were present at baseline in 21/43 (49%) patients. By partitioning the study population into four major groups according to the extend of WMH (Fazekas score 0 or ≥ 1) and the presence or absence of TE risk factors (CHA2DS2-VASc score 0 or ≥ 1), the TE risk as defined by CHA2DS2-VASc score ≥ 1, was associated with a higher incidence of WMH, Pearson χ2(1,N = 43)=3.95, p = 0.047.

The S100b (µg/l) levels increased significantly from baseline, (mean ± SD) 0.0472 ± 0.0182 to 0.0551 ± 0.0185 after CV, p = 0.001 and then decreased 7-10 days after CV to 0.0450 ± 0.0186, p &lt; 0.001. Subgroup analysis according to the presence of at least one TE risk factor as defined by CHA2DS2-VASc score showed that statistical significance of repeated measures ANOVA was maintained; for patients with no risk factors F (2,30)=12.59, p &lt; 0.001 and for patients with CHA2DS2-VASc score ≥1 F(2,36)=4.43, p &lt; 0.019.

Consecutive TMT scores improved successively after CV, being statistically and clinically significant for TMT-B (p &lt; 0.01) and ΔΤΜΤ (p = 0.005) between 7-10 days and 30 days after CV (Reliable Change Index &gt;1.96).

Conclusion

New brain lesions could not be detected on MRI after CV, but the high incidence of white matter hyperintensities and the transient increase in S100b may indicate transient or minor brain damage undetectable by MRI thus heightening the need to reevaluate thromboembolic risk prior to CV even in low risk patients.

Abstract Figure. S100b_TMT

Upholding ethical values and human rights at the frontier of TB research

Until recently, human rights have played a minor role in the fight against tuberculosis (TB), even less so in TB research. This is changing, however. The WHO's End TB Strategy and Ethics Guidance stress respect for human rights and ethical principles in every area of TB care, including research. The desired reductions in TB incidence and mortality are impossible without new tools and strategies to fight the disease. Yet, little suggests that the current state of TB research-including funding levels, evidence being produced, and community involvement-will alleviate concerns related to the availability, accessibility, and acceptability of TB diagnostics, drugs, and prevention in the near future. In this article, we consider these ethics concerns in relation to the right to enjoy the benefits of scientific progress and the right to health. We also reflect on community involvement in research and offer recommendations in the spirit of the rights to health and science, such as involving affected communities in all aspects of research planning, execution, and dissemination. Finally, we argue that states have a responsibility under international law for the continued realization of the right to health. This realization rests, in part, on the realization of the right to science.

P3595Risk factors, comorbidities and early dynamic change in high-sensitive cardiac troponin T -The importance of initial troponin level at presentation

Background

The one-hour troponin-algorithm is recommended together with a clinical evaluation for rule-in and rule-out of acute coronary syndrome (ACS) in the emergency department (ED). Since risk factors and many comorbidities are associated with small elevations of high-sensitive cardiac troponin T (hs-cTnT), their additive value for discrimination of ACS have been questioned. However, the importance of the initial troponin level for how risk factors and/or comorbidities associate with early dynamic change in hs-cTnT is poorly studied.

Purpose

To investigate the association between risk factors and early dynamic change of hs-cTnT among those with an elevated compared to non-elevated initial hs-cTnT.

Methods

This was a retrospective study among patients admitted to four urban emergency departments (ED) between 2014–2016 with the chief complaint of chest pain and with two clinical routine hs-cTnT measurements at presentation and at >30–104 minutes later. Clinical data from the ED visit were cross-referenced to national registers retrieving information on diagnoses and treatments to identify: cardiovascular disease (CVD, defined as previous myocardial infarction, stroke or peripheral vascular disease), hypertension (HT), hyperlipidemia (HL), diabetes mellitus (DM), chronic kidney disease (CKD), Heart failure (CHF) and atrial fibrillation (AF). The association between risk factors and early dynamic change was studied separately for those with an elevated (>14ng/L, dynamic change set as >20%) and a non-elevated (≤14ng/L, dynamic change set as >2ng/L) initial hs-cTnT.

Results

9278 patients were identified. All risk factors and comorbidities were more common among those with an elevated hs-cTnT. Dynamic change was present in 236 (3.4%) of 7024 patients with an initial hs-cTnT ≤14ng/L and 307 (13.6%) of 2254 with an initial hs-cTnT >14ng/L respectively. Among those with non-elevated initial hs-cTnT those with dynamic change were more likely to be older: age >70 (odds ratio (OR); 95% CI: 1.5; 1.1–2.0), have CVD (1.7: 1.2–2.5), HT (1.4; 1.1–1.8), eGFR<60 (1.8; 1.3–2.5) or AF (1.5; 1.0–2.4). Conversely, in patients with initial elevated hs-cTnT most conditions were negatively associated with early dynamic change: age >70 (0.5; 0.4–0.6), CVD (0.5; 0.4–0.7), HT (0.6; 0.46–0.8), eGFR<60 (0.4; 0.3–0.6), CHF (0.4; 0.3–0.5), AF (0.4; 0.3–0.6) and no risk factors were positively associated with dynamic change. Different cut-offs for dynamic change for instance >4ng/L (at initial hs-cTnT <14ng/L) and >50% (initial >14ng/L) were tested but did not affect the overall results.

Fig 1. Forest plot dynamic hs-cTnT

Conclusions

Many risk factors and comorbidities show opposite associations with early dynamic change of hs-cTnT depending on the baseline concentration. The findings stress the importance of initial troponin level when assessing patients with risk factors presenting with ACS symptoms in the ED, however further investigations are needed to establish the definite dependency.

Genetic testing for familial hypercholesterolemia among survivors of acute coronary syndrome

BACKGROUND

Familial hypercholesterolemia could be prevalent among patients with acute coronary syndrome.

OBJECTIVE

To investigate both the frequency of causative mutations for familial hypercholesterolemia (FH) and the optimal selection of patients for genetic testing among patients with an acute coronary syndrome (ACS).

METHODS

One hundred and sixteen patients with an ACS during 2009-2015 were identified through the SWEDEHEART registry. Patients who had either a high total cholesterol level ≥7 mmol L^-1 combined with a triglyceride level ≤2.6 mmol L^-1 , or were treated with lipid-lowering medication and had a total cholesterol level >4.9 mmol L^-1 and a triglyceride level ≤2.6 mmol L^-1 were included. Genetic testing was performed first with a regionally designed FH mutation panel (118 mutations), followed by testing with a commercially available FH genetic analysis (Progenika Biopharma).

RESULTS

A total of 6.9% (8/116) patients had a FH-causative mutation, all in the LDL-receptor. Five patients were detected on the panel, and further testing of the remaining 111 patients detected an additional 3 FH-causative mutations. Baseline characteristics were similar in FH-positive and FH-negative patients with respect to age, gender, prior ACS and diabetes. Patients with a FH-causative mutation had higher Dutch Lipid Clinical Network (DLCN) score (5.5 (5.0-6.5) vs 3.0 (2.0-5.0), P < 0.001) and a higher low-density lipoprotein level (5.7 (4.7-6.5) vs 4.9 (3.5-5.4), P = 0.030). The Dutch Lipid Clinical Network (DLCN) score had a good discrimination with an area under the curve of 0.856 (95% CI 0.763-0.949).

CONCLUSION

Genetic testing for FH should be considered in patients with ACS and high DLCN score.

Cells respond to deletion of CAV1 by increasing synthesis of extracellular matrix

A range of cellular functions have been attributed to caveolae, flask-like invaginations of the plasma membrane. Here, we have used RNA-seq to achieve quantitative transcriptional profiling of primary embryonic fibroblasts from caveolin 1 knockout mice (CAV1-/- MEFs), and thereby to gain hypothesis-free insight into how these cells respond to the absence of caveolae. Components of the extracellular matrix were decisively over-represented within the set of genes displaying altered expression in CAV1-/- MEFs when compared to congenic wild-type controls. This was confirmed biochemically and by imaging for selected examples. Up-regulation of components of the extracellular matrix was also observed in a second cell line, NIH-3T3 cells genome edited to delete CAV1. Up-regulation of components of the extracellular matrix was detected in vivo by assessing collagen deposition and compliance of CAV1-/- lungs. We discuss the implications of these findings in terms of the cellular function of caveolae.

TRPV4 inhibition attenuates stretch-induced inflammatory cellular responses and lung barrier dysfunction during mechanical ventilation

Mechanical ventilation is an important tool for supporting critically ill patients but may also exert pathological forces on lung cells leading to Ventilator-Induced Lung Injury (VILI). We hypothesised that inhibition of the force-sensitive transient receptor potential vanilloid (TRPV4) ion channel may attenuate the negative effects of mechanical ventilation. Mechanical stretch increased intracellular Ca²⁺ influx and induced release of pro-inflammatory cytokines in lung epithelial cells that was partially blocked by about 30% with the selective TRPV4 inhibitor GSK2193874, but nearly completely blocked with the pan-calcium channel blocker ruthenium red, suggesting the involvement of more than one calcium channel in the response to mechanical stress. Mechanical stretch also induced the release of pro-inflammatory cytokines from M1 macrophages, but in contrast this was entirely dependent upon TRPV4. In a murine ventilation model, TRPV4 inhibition attenuated both pulmonary barrier permeability increase and pro-inflammatory cytokines release due to high tidal volume ventilation. Taken together, these data suggest TRPV4 inhibitors may have utility as a prophylactic pharmacological treatment to improve the negative pathological stretch-response of lung cells during ventilation and potentially support patients receiving mechanical ventilation.

Fibrinolytic Proteins and Progression of Coronary Artery Disease in Relation to Gemfibrozil Therapy

Impaired fibrinolytic function, mainly due to increased plasma plasminogen activator inhibitor-1 (PAI-1) activity, is common in patients with manifest coronary artery disease (CAD) and a predictor of recurrent cardiovascular events. We investigated the relationships of plasma tissue-type plasminogen activator (tPA) and PAI-1 antigen levels, plasma PAI-1 activity and PAI 4/5-guanosine (4G/5G) genotype to CAD progression in 203 middle-aged men participating in the Lopid Coronary Angiography Trial (LOCAT).

A higher tPA antigen concentration, whether baseline or on-trial, was associated with a more severe global angiographic response (p < 0.05), an association mainly accounted for by progression of diffuse lesions in graft-affected segments (change in per-patient means of average diameters of segments haemodynamically related to bypass grafts). Plasma PAI-1 activity and mass concentration and 4G/5G PAI-1 genotype were unrelated to angiographic outcome measurements. tPA and PAI-1 antigen increased significantly in the gemfibrozil group (+11.3% and + 16.4%, respectively, p < 0.001), whereas there was no treatment effect on PAI-1 activity (median change 0.0%).

It is concluded that fibrinolytic function does not substantially influence progression of CAD as assessed by angiography in middle-aged men. Furthermore, pronounced long-term lowering of serum triglycerides by gemfibrozil treatment does not significantly affect the plasma PAI-1 activity level but increases the plasma tPA and PAI-1 antigen concentrations.

Tuberculosis, human rights and ethics considerations along the route of a highly vulnerable migrant from sub-Saharan Africa to Europe

Migrant health is a critical public health issue, and in many countries attention to this topic has focused on the link between migration and communicable diseases, including tuberculosis (TB). When creating public health policies to address the complex challenges posed by TB and migration, countries should focus these policies on evidence, ethics, and human rights. This paper traces a commonly used migration route from sub-Saharan Africa to Europe, identifying situations at each stage in which human rights and ethical values might be affected in relation to TB care. This illustration provides the basis for discussing TB and migration from the perspective of human rights, with a focus on the right to health. We then highlight three strands of discussion in the ethics and justice literature in an effort to develop more comprehensive ethics of migrant health. These strands include theories of global justice and global health ethics, the creation of 'firewalls' to separate enforcement of immigration law from protection of human rights, and the importance of non-stigmatization to health justice. The paper closes by reflecting briefly on how TB programs can better incorporate human rights and ethical principles and values into public health practice.

Abstract P5-02-03: Evaluating the feasibility of a web-based preference-tolerant randomized trial of risk-based vs. annual breast cancer screening: WISDOM study pilot

Background: The WISDOM Study (Women Informed to Screen Depending on Measures of risk) aims to examine the effectiveness of personalized breast cancer screening and to bring objective recommendations to the current mammography screening debate. The WISDOM Study is a 100,000 woman randomized trial with a preference-tolerant design that will determine if risk-based screening (RBS) vs. annual screening, is as safe, less morbid, enables prevention and is preferred by women. A pilot was conducted to test the logistics of online participation and examine the acceptance of the study design and approach.

Methods: Women were recruited from the UCSF site of the Athena Breast Health Network, a clinical care-research cohort of 110,000 women from the 5 University of California Medical Centers and Sanford Health. The pilot recruited women via email who were 40 -74 years of age with no history of breast cancer and a normal mammogram in the past year. Those interested visited the WISDOM Study website (wisdomstudy.org), signed up, elected randomization or self-selection, provided electronic consent using DocuSign (eConsent), and completed genetic testing (RBS arm). The Breast Cancer Surveillance Consortium (BCSC) model (standard risk factors, ethnicity, and breast density) in addition to genetic testing (9 genes and 75 SNPs) was used to calculate breast cancer risks that informed the start and frequency of screening for women in the RBS arm. BCSC was also used in the annual screening arm but did not inform mammography screening recommendations. The pilot used a mixed method approach (using enrollment data, Exit Survey data, individual interviews and focus groups) to assess enrollment preferences, randomization acceptance and overall study workflow.

Results: The online electronic enrollment process and patient engagement portal was successfully implemented. In total, 639 women were invited, 235 registered (34%), and 171 (27%) consented to the pilot. Of these, 74% (127) elected to be randomized, and 26% chose to self-assign (66% chose annual screening (29)). Mean age was 56 years and the ethnic breakdown of the cohort was: 79% White, 10% Asian, 7% Latino, 3% Black, 1% other. 92% of those in the risk-based arm of the study completed genetic testing and were given results; only one genetic mutation was identified and occurred in CHEK2. Within the RBS arm (78), mammography recommendations were: 61% no further mammography until the age of 50, 22% biennial, 11% annual, and 6% every 6 month alternating MRI and mammogram. Exit Survey data illuminated confusion in study arm names (risk-based vs. annual), randomization acceptance (74%), annual arm preference in the self-selection group (66%), eConsent satisfaction (90%), enrollment process ease of use (88%), and website content, navigation and appearance satisfaction (66%). The pilot concluded in May 2016 to allow for refinements prior to the full trial.

Conclusion: Our pilot demonstrates that the majority of women are willing to be randomized and participate in an online screening study to answer the important question on optimal breast cancer screening. The pilot study results will inform implementation of the 100,000 women WISDOM Study which launches in fall of 2016.

Citation Format: Stover Fiscalini A, Theiner S, Kaplan C, Sarrafan S, Sawyer S, Liang A, Rosenberg-Wohl S, Gordon D, Frick M, Borowsky A, Anton-Culver H, Naeim A, LaCroix A, Cink T, Collaboration Athena Breast Health Network and Advocate Partners, Esserman L, van 't Veer L. Evaluating the feasibility of a web-based preference-tolerant randomized trial of risk-based vs. annual breast cancer screening: WISDOM study pilot [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 P5-02-03.

Re-inventing adherence: toward a patient-centered model of care for drug-resistant tuberculosis and HIV

BACKGROUND

Despite renewed focus on molecular tuberculosis (TB) diagnostics and new antimycobacterial agents, treatment outcomes for patients co-infected with drug-resistant TB and human immunodeficiency virus (HIV) remain dismal, in part due to lack of focus on medication adherence as part of a patient-centered continuum of care.

OBJECTIVE

To review current barriers to drug-resistant TB-HIV treatment and propose an alternative model to conventional approaches to treatment support.

DISCUSSION

Current national TB control programs rely heavily on directly observed therapy (DOT) as the centerpiece of treatment delivery and adherence support. Medication adherence and care for drug-resistant TB-HIV could be improved by fully implementing team-based patient-centered care, empowering patients through counseling and support, maintaining a rights-based approach while acknowledging the responsibility of health care systems in providing comprehensive care, and prioritizing critical research gaps.

CONCLUSION

It is time to re-invent our understanding of adherence in drug-resistant TB and HIV by focusing attention on the complex clinical, behavioral, social, and structural needs of affected patients and communities.

EGR2 mutations define a new clinically aggressive subgroup of chronic lymphocytic leukemia

Recurrent mutations within EGR2 were recently reported in advanced-stage chronic lymphocytic leukemia (CLL) patients and associated with a worse outcome. To study their prognostic impact, 2403 CLL patients were examined for mutations in the EGR2 hotspot region including a screening (n=1283) and two validation cohorts (UK CLL4 trial patients, n=366; CLL Research Consortium (CRC) patients, n=490). Targeted deep-sequencing of 27 known/postulated CLL driver genes was also performed in 38 EGR2-mutated patients to assess concurrent mutations. EGR2 mutations were detected in 91/2403 (3.8%) investigated cases, and associated with younger age at diagnosis, advanced clinical stage, high CD38 expression and unmutated IGHV genes. EGR2-mutated patients frequently carried ATM lesions (42%), TP53 aberrations (18%) and NOTCH1/FBXW7 mutations (16%). EGR2 mutations independently predicted shorter time-to-first-treatment (TTFT) and overall survival (OS) in the screening cohort; they were confirmed associated with reduced TTFT and OS in the CRC cohort and independently predicted short OS from randomization in the UK CLL4 cohort. A particularly dismal outcome was observed among EGR2-mutated patients who also carried TP53 aberrations. In summary, EGR2 mutations were independently associated with an unfavorable prognosis, comparable to CLL patients carrying TP53 aberrations, suggesting that EGR2-mutated patients represent a new patient subgroup with very poor outcome.

rApi m 3 and rApi m 10 improve detection of honey bee sensitization in Hymenoptera venom-allergic patients with double sensitization to honey bee and yellow jacket venom

Recombinant allergens improve the diagnostic precision in Hymenoptera venom allergy (HVA), in particular in patients with double sensitization to both honey bee (HBV) and yellow jacket venom (YJV). While currently available vespid allergens allow the detection of >95% of YJV-allergic patients, the sensitization frequency to the only available HBV marker allergen rApi m 1 in HBV-allergic patients is lower. Here, we demonstrate that sIgE to additional HBV marker allergens rApi m 3 and rApi m 10 allows the detection of genuine HBV sensitization in 46-65% of Api m 1 negative sera. This is of particular relevance in patients with double sensitization to HBV and YJV that did not identify the culprit insect. Addition of sIgE to rApi m 3 and rApi m 10 provides evidence of HBV sensitization in a large proportion of rApi m 1-negative patients and thus provides a diagnostic marker and rationale for VIT treatment with HBV, which otherwise would have been missing.