Utilization of cardiac MRI for the assessment of suspected rejection with negative biopsy in heart transplant recipients

Background

Heart transplant (HTx) patients can develop graft dysfunction (GD) without biopsy evidence of cell or antibody mediated rejection. Cardiac MRI (CMR) can detect inflammatory or infiltrative causes of cardiomyopathy however CMR findings in HTx recipients with GD have not been previously described.

Purpose

We sought to identify CMR characteristics of HTx patients with GD, and evaluate its additive value in its diagnosis and prognosis.

Methods

CMR has been performed routinely to evaluate GD at our institutions. There were 37 HTx recipients who presented with acute decline in left ventricular ejection fraction (LVEF) of <50% and >10% from baseline, with no biopsy evidence of rejection between 2007 and 2018. Coronary angiogram with IVUS was done to rule out allograft vasculopathy. Treatment of GD was per discretion of the treating clinician. Responders were defined as those with LVEF improvement >10% at 180 days or greater post-presentation. LV and RV indices, the presence and pattern of late gadolinium enhancement (LGE) were determined by CMR.

Results

There were 34% females and mean age at transplant was 49±13 years. Median time from HTx to GD was 1.2 years. Presenting symptoms were heart failure (n=25), cardiogenic shock (n=1) and 11 patients were asymptomatic. Mean LVEF at presentation was 37±12% and donor specific antibodies were detected in 38% patients. Most patients were treated with steroid bolus (n=29), and/or plasmapheresis (n=23). There were no major changes made in immunosuppression in 6 patients. Delayed enhancement MRI was performed with standard inversion-recovery (IR) gradient echo sequences, between 5 and 20 minutes after institutional-standard protocol administration of IV gadolinium contrast. Biventricular LGE was present in 18/37 (49%) patients with GD and was more prevalent in responders (57%, 13 of 23) than non-responders (35%, 5 of 14), although not statistically significant (p=0.21). There were two patterns of LGE noted: 1) Diffuse epicardial (10 patients out which 9 were responders) and 2) Patchy pattern with non-specific distribution (8 patients out of which 4 were responders). Myocardial edema by triple IR sequencing was seen in 6 patients, all having diffuse epicardial pattern of enhancement matching the delayed enhancement pattern. When comparing different treatment groups, among those treated for GD (n=31), 12 of 21 (57%) responders had LGE and 4 of 10 (40%) non-responders had LGE (p=0.37), a pattern similar to the broader population. Among those not treated for GD (n=6), 1 of 2 responders had LGE and 1 of 4 non-responders had LGE (p=0.5).

Conclusion

CMR identified inflammation as a potential cause of GD in approximately 50% of HTx patients. There are 2 distinct patterns of LGE observed in GD, diffuse epicardial (56%) and patchy (44%). Although the presence of LGE in itself is not associated with myocardial recovery, 90% of patients with a diffuse epicardial pattern have recovery of GD.

Funding Acknowledgement

Type of funding source: None

Hemoglobin SE Disease Presenting as a High-Altitude Massive Splenic Infarction Complicated by Hemorrhagic Conversion and Splenectomy

Hemoglobin SE (HbSE) disease is a hemoglobinopathy resulting from the combination of hemoglobin S (HbS) and hemoglobin E (HbE) genotypes. It may present as a vaso-occlusive crisis (VOC) in the setting of an acute stressor. Herein, we present a case of undiagnosed HbSE disease presenting as a massive splenic infarct in the setting of high-altitude exposure. A 55-year-old female of South Asian descent presented with acute left upper quadrant abdominal pain after hiking in the Swiss Alps four days previously. Laboratory testing revealed that she had hemolytic anemia, and computed tomography (CT) imaging showed a greater than 50% splenic infarction. After the initiation of anticoagulation, she experienced a hemorrhagic conversion of the initial splenic infarct resulting in acute hemodynamic decompensation. She initially underwent vascular intervention with arterial plugging, coiling, and embolization but ultimately required a splenectomy and partial colectomy upon developing a large splenic hematoma. Hemoglobin electrophoresis was consistent with hemoglobin SE disease. Hemoglobin variants, especially combined heterozygosity, are rare and have the potential to present as a vaso-occlusive crisis in the setting of acute chemical and physiological stresses. Only 43 cases of hemoglobin SE disease have been previously reported and one other occurrence in the setting of high altitude. Conservative management is recommended when a diagnosis of sickle cell trait (SCT) is definite, in comparison with cardioembolic phenomena, in which antiplatelet and anticoagulant therapy should be initiated. Hemoglobin SE disease is a rare heterozygous hemoglobinopathy resulting from the combination of hemoglobin variants geographically separated by thousands of miles. Currently, there are no strict guidelines supporting anticoagulation for the management of VOC in hemoglobinopathies. Splenic infarct in HbSE disease should be managed similarly to SCT/sickle cell disease (SCD) with fluids and analgesia, and anticoagulation should be limited to confirmed thromboembolic events and with the insight of an anticoagulant specialist.

Quality Differences in Wooden Breast Meat Marinated with Commercial Ingredients

ObjectivesWooden breast (WB) is a Pectoralis major muscle myopathy that impacts the quality of broiler breast meat, which is a current significant challenge for the poultry industry. While WB has been thoroughly researched in recent years, there has not been a resolution to this issue. Therefore, it is necessary to explore potential solutions to mitigate the undesirable characteristics of WB. The objective of this research was to evaluate differences in quality between chicken breasts classified as normal (NOR), moderately woody (MOD), and severely woody (SEV) that were marinated with control (water), traditional (sodium phosphate and salt), or clean label (potassium carbonate and salt) marinades.Materials and MethodsChicken breasts from broilers were graded NOR, MOD, SEV based on the severity of WB. Breasts were sized to 30 ± 2 mm to control variability in breast thickness. Three separate treatment marinades were applied to 40 lb batches of each WB severity 24 h postmortem. Treatments were tumbled for 30 min at 12 rpm under vacuum (20–25 mmHg). Tumble yields were measured. The breasts were individually frozen in a CO2 cabinet to –62.2°C and stored at –17.8°C. A 3 × 3 factorial structure within a randomized complete block design with 3 replications of 40 lbs (Day 1, Day 2, Day 3) were used to evaluate the impact of marinade (control, traditional, clean label) and WB severity (NOR, MOD, SEV) on tumble yields. Similarly, a 2 × 3 factorial structure was used to analyze the effect of marinade (traditional and clean label) and WB severity (NOR, MOD, SEV) on sensory attributes.ResultsWhen averaged over WB severity, the clean label marinade had a greater tumble yield (P < 0.05) than the traditional marinade. When averaged over marinade, the NOR had a greater tumble yield (P < 0.05) than the MOD and SEV treatments, which did not differ from each other (P > 0.05).Descriptive sensory results revealed that both marinated SEV were crunchier and less tender (P < 0.05) than MOD and NOR, and MOD was less tender (P < 0.05) than NOR. The clean SEV was chewier (P < 0.05) than all MOD and NOR treatments, but the traditional SEV was only chewier (P < 0.05) than the NOR. Interaction was significant (P < 0.05) for mushy, initial juiciness, and overall juiciness. These attributes differed (P < 0.05) for WB severity but not marinade treatment. When averaged over marinade, NOR was mushier than the MOD, which was mushier than the SEV, and the SEV and MOD were juicier than NOR.Consumer acceptability results indicated that clean and traditional SEV were less acceptable (P < 0.05) than MOD and traditional NOR; no difference (P > 0.05) existed between MOD and NOR for both marinades. In addition, when averaging over WB severity, the traditional marinade was preferred (P < 0.05) over the clean label marinade. Thus, differences in WB severities were more apparent in the clean label than the traditional marinade, which indicates that even though the clean label samples were tender, it may not be advisable to utilize that marinade formulation in place of traditional marinades with SEV woody breast meat.ConclusionThe use of salt and sodium phosphate or potassium carbonate in a marinade improves eating quality characteristics of MOD and SEV woody breast. However, differences remain between NOR and SEV in tenderness, gumminess and crunchiness that negatively impact the consumer acceptability of broiler breast meat.

Chronic Dyrk1 Inhibition Delays the Onset of AD-Like Pathology in 3xTg-AD Mice

There is a critical need for new treatment approaches that can slow or prevent the progression of Alzheimer's disease (AD). Targets that act simultaneously on multiple relevant pathways could have significant therapeutic potential. Dual-specificity tyrosine phosphorylation-regulated kinase 1A (Dyrk1a) phosphorylates both amyloid precursor protein (APP) and tau. Dyrk1a is upregulated in post-mortem brains of AD patients, and such elevated expression is associated with cognitive deficits. We previously demonstrated that small molecule inhibition of Dyrk1 is well-tolerated and reduces amyloid plaques and pathological forms of tau in 3xTg-AD mice if administered after formation of these pathologies. However, while insoluble forms of hyperphosphorylated tau were reduced by Dyrk1 inhibition, overt neurofibrillary tangle (NFT) pathology remained unchanged. Herein, we specifically test the hypothesis that inhibition of Dyrk1 prior to NFT formation will delay the onset of pathology. 3xTg-AD mice were treated chronically, beginning at 6 months of age, prior to NFT pathology. Mice were dosed daily for either 3 or 6 months and amyloid and tau pathology were assessed. We show that chronic Dyrk1 inhibition reduces insoluble forms of amyloid beta peptides (Aβ) and hyper-phosphorylated tau long-term and that these reductions are associated with dramatic delay in the onset of both amyloid plaques and NFTs. In addition, we show that DYR219, a potent and selective small molecule Dyrk1 inhibitor, induces degradation of Dyrk1a protein, likely contributing to the efficacy of this small molecule approach in vivo. Collectively, these results suggest that therapeutic strategies targeting tau phosphorylation will show the greatest effect if administered very early in the pathogenesis of AD.

A Randomized Controlled Trial of the Safety and Immunogenicity of Tetanus, Diphtheria, and Acellular Pertussis Vaccine Immunization During Pregnancy and Subsequent Infant Immune Response

Background

Immunization of pregnant women with tetanus-diphtheria-acellular pertussis vaccine (Tdap) provides protection against pertussis to the newborn infant.

Methods

In a randomized, controlled, observer-blind, multicenter clinical trial, we measured the safety and immunogenicity of Tdap during pregnancy and the effect on the infant's immune response to primary vaccination at 2, 4, and 6 months and booster vaccination at 12 months of age. A total of 273 women received either Tdap or tetanus-diphtheria (Td) vaccine in the third trimester and provided information for the safety analysis and samples for the immunogenicity analyses; 261 infants provided serum for the immunogenicity analyses.

Results

Rates of adverse events were similar in both groups. Infants of Tdap recipients had cord blood levels that were 21% higher than maternal levels for pertussis toxoid (PT), 13% higher for filamentous hemagglutinin (FHA), 4% higher for pertactin (PRN), and 7% higher for fimbriae (FIM). These infants had significantly higher PT antibody levels at birth and at 2 months and significantly higher FHA, PRN, and FIM antibodies at birth and 2 and 4 months, but significantly lower PT and FHA antibody levels at 6 and 7 months and significantly lower PRN and FIM antibody levels at 7 months than infants whose mothers received Td. Differences persisted prebooster at 12 months for all antigens and postbooster 1 month later for PT, FHA, and FIM.

Conclusions

This study demonstrated that Tdap during pregnancy results in higher levels of antibodies early in infancy but lower levels after the primary vaccine series.

Clinical Trials Registration

NCT00553228.

LB13. Trivalent Hepatitis B (HepB) Vaccine Yields Superior Seroprotection Rates in Adults: Results from the Phase 3 Double-Blind, Randomized Study Comparing Immunogenicity and Safety of a 3-Dose Regimen of Sci-B-Vac™ and Engerix B® (PROTECT)

Background

Many adults fail to achieve seroprotection after receiving 3 doses of monovalent HepB vaccines such as Engerix-B® and the response decreases with age and with common co-morbidities. Sci-B-Vac™ is a trivalent HepB vaccine produced in mammalian cells, adjuvanted with aluminum hydroxide, which in addition to small S antigen, contains preS1 and preS2 antigens expressing highly immunogenic T- and B-cell epitopes that may enhance seroprotection rates (SPR) in adults.

Methods

In a multicentre study, the immunogenicity of 10 µg dose of Sci-B-Vac™ was compared with a 20-µg dose of Engerix-B® given at days 0, 28, and 168 (NCT03393754). Randomization was stratified by study center and age (18–44, 45–64, ≥65 years). Immunogenicity, including SPR (% subjects with anti-HBs levels ≥10 mIU/mL), and safety outcomes were followed to Day 336. The co-primary objectives were (1) non-inferiority in adults ≥18 years and (2) superiority in adults ≥45 years of SPR, 4 weeks after the third dose.

Results

Of 1,607 randomized subjects, 42.3% were from United States, 41.6% EU, and 16.1% Canada. Males (38.5%) and females (61.5%) were enrolled to 18–44 (18.6%), 45–64 (44.6%), and ≥ 65 year (36.8%) age groups. Both co-primary endpoints were met. In the non-inferiority analysis, SPR in Sci-B-Vac™ recipients aged ≥18 years was 91.4% vs. 76.5% for Engerix-B®; SPR difference: 14.9%; 95% confidence interval (CI) [11.2%, 18.6%]. Superiority analysis showed that SPR in Sci-B-Vac™ recipients aged ≥45 years was 89.4% vs. 73.1% for Engerix-B®—SPR difference: 16.4%; 95% CI [12.2%, 20.7%] (figure). Significantly higher SPR for Sci-B-Vac™ vs. Engerix-B® was noted in subgroups (gender, BMI, diabetes, smoking and particularly age—SPR difference for 45–64 (14.7% [9.8–19.8%]) and ≥ 65 (18.9% [11.6–26.1%]) years. No major safety signals were observed; solicited and unsolicited adverse events were consistent with the known vaccine safety profiles.

Conclusion

Sci-B-Vac™ met immunogenicity endpoints for non-inferiority in adults aged ≥ 8 years and was superior in adults aged ≥45 years, compared with the monovalent vaccine, Engerix-B®. Sci-B-Vac™ SPR was higher compared with Engerix-B® in key subgroups. No safety signals were observed and safety and tolerability were consistent with the known profile of Sci-B-Vac™.

Disclosures

Timo Vesikari, MD, VBI (Grant/Research Support, I have received funding from VBI to carry out the reported clinical trial in Finland), Joanne M. Langley, MD, VBI Vaccines (Grant/Research Support), Johanna Spaans, BSc, MSc, VBI Vaccines (Employee), Nathalie Machluf, PhD, SciVac Ltd. (Employee), Dave Anderson, PhD, VBI Vaccines, Inc. (Employee, Shareholder), Vlad Popovic, MD, VBI Vaccines (Employee), Francisco Diaz-Mitoma, MD, VBI Vaccines, Inc. (Consultant, Shareholder, Independent Contractor). Other Authors: No reported disclosures.