Conference report: WHO meeting summary on mRNA-based tuberculosis vaccine development

Tuberculosis (TB) is a global health emergency. Across the globe, approximately 2 billion people are currently infected with Mycobacterium tuberculosis (Mtb), and of those, 5-10% may progress to become ill and potentially transmit the bacterium. In 2021, nearly 10.6 million people developed TB disease and 1.6 million died. There is an urgent need for accelerated development of new TB-focused interventions, in particular, improved TB vaccines. However, progress in developing highly effective TB vaccines has been slow and is chronically under-resourced. The mRNA vaccine platform may offer an opportunity to accelerate development of new TB vaccines. In April 2023, the World Health Organization convened global experts to discuss the feasibility and potential value of mRNA-based vaccines for TB. Here we report on meeting deliberations related to the current TB vaccine pipeline and potential novel antigens, the status of efforts to identify correlates of protection, potential clinical development strategies and considerations for community acceptance of new TB vaccines based on this relatively new platform. The role of industry collaborations, ethics, social science, and responsibility to the global community regarding transparency and manufacturing capacity building were discussed through expert presentations and panel sessions. The overall conclusion of the meeting is that mRNA-based vaccines constitute a potentially powerful new tool for reducing the global burden of TB.

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.

Clinical trials of tuberculosis vaccines in the era of increased access to preventive antibiotic treatment

Approximately 10·6 million people worldwide develop tuberculosis each year, representing a failure in epidemic control that is accentuated by the absence of effective vaccines to prevent infection or disease in adolescents and adults. Without effective vaccines, tuberculosis prevention has relied on testing for Mycobacterium tuberculosis infection and treating with antibiotics to prevent progression to tuberculosis disease, known as tuberculosis preventive treatment (TPT). Novel tuberculosis vaccines are in development and phase 3 efficacy trials are imminent. The development of effective, shorter, and safer TPT regimens has broadened the groups eligible for TPT beyond people with HIV and child contacts of people with tuberculosis; future vaccine trials will be undertaken in an era of increased TPT access. Changes in the prevention standard will have implications for tuberculosis vaccine trials of disease prevention, for which safety and sufficient accrual of cases are crucial. In this paper, we examine the urgent need for trials that allow the evaluation of new vaccines and fulfil the ethical duty of researchers to provide TPT. We observe how HIV vaccine trials have incorporated preventive treatment in the form of pre-exposure prophylaxis, propose trial designs that integrate TPT, and summarise considerations for each design in terms of trial validity, efficiency, participant safety, and ethics.

Developing tuberculosis vaccines for people with HIV: consensus statements from an international expert panel

New tuberculosis vaccine candidates that are in the development pipeline need to be studied in people with HIV, who are at high risk of acquiring Mycobacterium tuberculosis infection and tuberculosis disease and tend to develop less robust vaccine-induced immune responses. To address the gaps in developing tuberculosis vaccines for people with HIV, a series of symposia was held that posed six framing questions to a panel of international experts: What is the use case or rationale for developing tuberculosis vaccines? What is the landscape of tuberculosis vaccines? Which vaccine candidates should be prioritised? What are the tuberculosis vaccine trial design considerations? What is the role of immunological correlates of protection? What are the gaps in preclinical models for studying tuberculosis vaccines? The international expert panel formulated consensus statements to each of the framing questions, with the intention of informing tuberculosis vaccine development and the prioritisation of clinical trials for inclusion of people with HIV.

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.

Comparing timelines and evidence available to support new TB, HIV, and HCV drug approvals: The same, only different

Background

Tuberculosis (TB), human immunodeficiency virus (HIV), and hepatitis C virus (HCV) share a global presence and propensity to disproportionately affect marginalized populations. However, over recent decades, many fewer drugs have been brought to market for TB than for the others. Although three new anti-TB drugs have been approved in the US or Europe in the last 10 years, uptake of these drugs has been limited. Using case examples of drugs developed recently for TB, HIV, and HCV, we explore possible reasons. We examine the use and effect of regulatory pathways intended to address weak economic incentives in the face of urgent, unmet needs; evaluate the extent of data underpinning authorizations for these indications; document development timelines and evidence available at the time of each approval; consider explanations for observed differences; and discuss the implications for clinical guidelines and use.

Methods and findings

For each indication, we selected two drugs: one recently approved and one approved between 2012 and 2014, when the first new anti-TB drug from a novel class in more than 40 years received marketing authorization. We calculated time from first published peer-reviewed evidence of activity to date of approval; the number of phase 1, 2, and 3 trials; the number of trial participants randomized to treatment arms containing the drug; and the total number of participants in each trial from the individual drug approval packages. We found that the two TB drugs took longer to gain approval (8.0 and 19.2 years for bedaquiline and pretomanid, respectively) despite availing of special regulatory pathways meant to expedite approval, when compared to the HIV (2.6 years for dolutegravir and 4.7 years for doravirine) and HCV drugs (3.2 and 1.6 years for sofosbuvir and glecaprevir/pibrentasvir, respectively). Moreover, fewer participants were studied prior to TB drug approvals (380 and 879) than prior to approvals for HIV (1598 and 979) and for HCV (2291 and 2448) drugs.

Conclusions

The dramatic disparities observed in TB drug development reaffirm the importance of several actions. Increased investment in TB research and development is necessary to rapidly advance drugs through the pipeline. Development plans and partnerships must provide safety and efficacy evidence on combinations and durations that are relevant to real-world use in heterogeneous populations. Reliable, validated surrogate markers of relapse-free cure are essential to decrease the duration and cost of TB treatment trials and increase the confidence and speed with which new regimens can advance. Lastly, regulators and normative bodies must maintain high evidentiary standards for authorization while ensuring timely and broad approval for TB drugs and regimens.

End-point definition and trial design to advance tuberculosis vaccine development

Tuberculosis (TB) remains a leading infectious cause of death worldwide and the coronavirus disease 2019 pandemic has negatively impacted the global TB burden of disease indicators. If the targets of TB mortality and incidence reduction set by the international community are to be met, new more effective adult and adolescent TB vaccines are urgently needed. There are several new vaccine candidates at different stages of clinical development. Given the limited funding for vaccine development, it is crucial that trial designs are as efficient as possible. Prevention of infection (POI) approaches offer an attractive opportunity to accelerate new candidate vaccines to advance into large and expensive prevention of disease (POD) efficacy trials. However, POI approaches are limited by imperfect current tools to measure Mycobacterium tuberculosis infection end-points. POD trials need to carefully consider the type and number of microbiological tests that define TB disease and, if efficacy against subclinical (asymptomatic) TB disease is to be tested, POD trials need to explore how best to define and measure this form of TB. Prevention of recurrence trials are an alternative approach to generate proof of concept for efficacy, but optimal timing of vaccination relative to treatment must still be explored. Novel and efficient approaches to efficacy trial design, in addition to an increasing number of candidates entering phase 2-3 trials, would accelerate the long-standing quest for a new TB vaccine.

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 <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 (<0.8) stenosis on FFR, p > 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 <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.

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<0.001, see figure A). 8 CMR+ patients (10%) had hsTNT in the normal range (<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<4 pg/ml) as defined by CMR, leading to a reduction of 23.4% of CMR exams. An upper cut-off value of >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 (<14 pg/ml). A lower cut-off value of <4 pg/ml ruled out AM with very high negative predictive value, whereas an upper cut-off of >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 <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<0,001, LAGLS-cond F(2,78)=23.3, p<0,001, LAGLS-contr F(2,78)=39.7, p<0,001, LAEF F(2,80)=28.5, p<0.001 and LVEF F(2,80)=8.4, p<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 <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<0.001, P-selectin: F(2,84)=8.69, p<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<0.01). Similarly, MACE (3.3% vs. 5.3%, p<0.01) and NACE (4.0% vs. 5.7% p<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

Public investments in the clinical development of bedaquiline

Introduction

In 2012, bedaquiline became the first new treatment from a novel class to be approved for tuberculosis in nearly five decades and is now a core component of the standard of care for multidrug-resistant tuberculosis. In addition to the originator pharmaceutical company, Janssen, a range of governmental and non-profit entities have contributed to the development of bedaquiline.

Materials and methods

We identified various avenues of public investments in the development of bedaquiline: direct funding of clinical trials and a donation programme, tax credits and deductions, and revenues resulting from the priority review voucher (PRV) awarded to the originator. Data on investments were gathered through contact with study leads and/or funders; for non-responses, published average costs were substituted. The originator company’s expenses were estimated by similar methods. Tax credits and deductions were calculated based on estimated originator trial costs and donation expenses. The value of the PRV was estimated by application of a published model.

Results

Public contributions through clinical trials funding were estimated at US$109–252 million, tax credits at US$22–36 million, tax deductions at US$8–27 million, administration of a donation programme at US$5 million, PRV revenues at US$300–400 million. Total public investments were US$455–747 million and originator investments were US$90–240 million (if capitalized and risk-adjusted, US$647–1,201 million and US$292–772 million, respectively).

Conclusions

Estimating the investments in the development of a medicine can inform discussions regarding fair pricing and future drug development. We estimated that total public investments exceeded the originator’s by a factor of 1.6–5.1.

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 < 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 < 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 < 0.001 and for patients with CHA2DS2-VASc score ≥1 F(2,36)=4.43, p < 0.019.

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

Using theory of change frameworks to develop evaluation strategies for research engagement: results of a pre-pilot study

INTRODUCTION

Inadequate community and stakeholder engagement can lead to accusations that research is unethical and can delay or slow research or translation of results to practice. Such experiences have led major funders as well as regulatory and advisory bodies to establish minimal requirements for community and stakeholder engagement in HIV and other clinical research. However, systematic efforts to formally evaluate the contributions and impact of particular practices are lacking.

METHODS

A theory of change framework aligned with Good Participatory Practice for TB clinical trials was used to develop a set of measures for use in a minimally burdensome survey of trial implementing sites. The survey was pre-piloted with three TB trial sites in North America, South America and Asia to assess the feasibility of surveying global research sites in a systematic way, and to see if the measures captured informative variation in the use of engagement strategies and desired outcomes. Surveys were conducted at baseline and six months. In-depth interviews were conducted with site staff prior to the baseline survey to understand how sites conceptualized the concepts underlying the framework and the extent to which they viewed their work as aligned with the framework.

RESULTS

Survey measures captured considerable variability in the intensity and variety of engagement strategies, both across sites and within sites over time, and moderate variability in outcomes. Interviews indicated that underlying concepts were often unfamiliar to staff at baseline, but the goals of engagement aligned well with existing values.

CONCLUSIONS

Brief, targeted surveys of trial sites to characterize use of broad strategies, specific practices and some outcomes are a feasible option for evaluating good participatory practice. Additional testing is warranted to assess and enhance validity, reliability and predictive value of indicators. Options for collecting outcome measures through additional objective means should be explored.

A Community Perspective on the Inclusion of Pregnant Women in Tuberculosis Drug Trials

Affecting both mother and the existing pregnancy, tuberculosis (TB) increases the likelihood of poor birth outcomes. Despite substantial clinical need for TB prevention and treatment, pregnant women remain neglected by research initiatives. As members of 3 community advisory boards that provide input into TB drug trials, we offer a community perspective on the inclusion of pregnant women in TB drug research and discuss (1) our perspective on the risk/benefit tradeoff of including pregnant women in research to address different forms of TB; (2) recent examples of progress in this area; (3) lessons learned from the human immunodeficiency virus research field, where pregnant women have enjoyed better-although imperfect-representation in research; and (4) recommendations for different stakeholders, including researchers, regulatory authorities, ethics committees, and policymakers.

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.