High-sensitivity Assay Research Articles

High-sensitivity cardiac troponin I and T kinetics after coronary artery bypass grafting in relation to current definitions of myocardial infarction: a systematic review and meta-anal

Abstract Background Cardiac troponins – either cardiac troponin T (cTnT) or cardiac troponin I (cTnI) – are the preferred biomarkers for the diagnosis of myocardial infarction (MI), also after coronary artery bypass grafting (CABG), also known as type 5 MI. Two distinct arbitrarily chosen definitions of MI have been formulated, proposing different diagnostic cTn cut-off concentrations for both cTnT and cTnI (defined by multiples of the 99th percentile upper reference limit of 10x, 35x or 70x URL, with or without need for additional electrocardiographical or imaging findings). Remarkably, these cut-off values are not (yet) validated for the current high-sensitivity (hs-cTn) assays. Purpose Investigating the kinetics of hs-cTnT and hs-cTnI in relation to the current definitions of myocardial infarction type 5 in patients undergoing isolated CABG. Methods A systematic search was applied to MEDLINE and EMBASE. The search terms were “coronary artery bypass” AND “high-sensitivity cardiac troponin”, including alternative names and abbreviations. All studies reporting hs-cTnT or hs-cTnI on at least two different time points were included. Hs-cTn concentrations were extracted, stratified and normalized to the URL of the assay. The search was performed by 2 independent reviewers, in agreement with the PRISMA guidelines. Results For hs-cTnT, and hs-cTnI, 15 (2646 patients) and 18 studies (1760 patients) were included for meta-analysis, respectively. The mean age of the total hs-cTnT and hs-cTnI patient population was 65 (11) and 63 (11) years, 22% and 21% was female, respectively. Preoperative hs-cTnT and hs-cTnI was 1.2xURL (mean, 95% CI: 0.9–1.4) and 6.1xURL (4.9–7.2), respectively. Peak hs-cTnT and hs-cTnI was reached 6–8h postoperative up to 44.9xURL (28.6–61.1) and 135xURL (109–161), respectively (figure 1). For patients where MI-5 was ruled out, peak hs-cTnT and hs-cTnI level was 43.9xURL (20.1–67.6) and 97.1xURL (20.6–214) respectively. Peak hs-cTnT and hs-cTnI concentrations were dependent on surgical strategy. Patients undergoing off-pump CABG, reached a peak 16–24h post-operatively (hs-cTnT: 13.4xURL, 8.1–18.8) and (hs-cTnI: 60.6xURL, 47.0–74.2). This was notably different from on-pump CABG, where peak hs-cTnT and hs-cTnI was reached 6–8h postoperative (44.8xURL, 37.8–51.9) and (144xURL, 114–174) respectively. MI incidence was 2.7% (range 0–7.0%) and 6.9% (range 0–32%) and the 30-day mortality was ranging from 0–4% and 0–2.5% for hs-cTnT and hs-cTnI respectively. Conclusion Postoperative hs-cTn surpasses most of the proposed cut-off concentrations by current definitions of type 5 MI, for hs-cTnT but especially for hs-cTnI. Differences in hs-cTn release following on-pump versus off-pump CABG were also observed, implying the need for different cut-off values for different surgical strategies. Furthermore, future clinical studies should focus on the diagnostic accuracy of cTn in type 5 MI and the re-evaluation of hs-cTn cut-off values in particular. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMw Veni grant

Agreement between high-sensitivity C-reactive protein and C-reactive protein assays

Abstract Background High sensitivity C-reactive protein (hs-CRP) is a biomarker used for risk prediction for cardiovascular disease (CVD) by assessing low concentrations of inflammatory markers. Measurements of regular CRP assays have become very sensitive too with a detection limit of 0.03mg/dL, while also being more available and cheaper. The aim of this study is to compare the association between CRP and hs-CRP. Methods This study compared CRP and hs-CRP serum concentrations and data acquired by medical chart review of 590 patients from 11/2017 to 10/2018 of our cardiology outpatient clinic who were divided into hs-CRP and CRP risk groups for CVD events: low<0.1 mg/dL, average 0.1–0.3mg/dL, high>0.3mg/dL. The agreement of classification in hs-CRP and CRP risk groups was assessed by kappa statistic, with Kappa coefficient of <0.20, 0.21–0.40, 0.41–0.60, 0.61–0.80, 0.81–0.99 interpreted as slight, fair, moderate, substantial and almost perfect agreement, respectively. Bland-Altman (BA) analysis was used to assess agreement between hs-CRP and CRP by plotting the mean of the two measurements on the x-axis against the mean difference of CRP - hs-CRP on the y-axis. Results Out of all 590 patients, 37.7% were in low risk, 33.9% in average risk and 28.5% in high risk hs-CRP group. Some group changes occurred after reclassification of the patients according to CRP measurements. Eight percent of patients reclassified into a higher risk group, 0.7% into a lower risk group, while 91.4% remained in the same risk group as determined by hs-CRP (kappa: 0.87; p<0.001) (Tab. 1). Important to note, there was a 100% agreement between the high-risk CRP and hs-CRP group patient classification. BA-plot displayed a fixed bias with an average difference between the two laboratory tests for CRP and hs-CRP of 0.02 mg/dL±0.09SD with only sporadic outliers (Fig. 1). The upper limit of agreement was 0.12 and lower limit of agreement was −0.07. In the lower range of CRP values, measurements were tightly clustered around the average difference. Greater variability could be observed at higher serum level of the inflammatory biomarker in the BA-plot with a bias to higher CRP concentrations than hs-CRP concentrations at values greater than 0.5mg/dL. This proportional bias, which was further demonstrated by linear regression analysis, does not affect the risk predicting qualities of hs-CRP or CRP for CVD because the cut-off values for risk groups (0.1mg/dL for low risk, 0.3mg/dL for high risk) are all below this threshold. Conclusion A close agreement between measurements of hs-CRP and CRP assays was identified, therefore regular CRP assays could replace hs-CRP for cardiac risk assessment. Benefits for clinical implementation are: First, CRP assessment is routinely available in most laboratories compared to hs-CRP. Second, CRP is less costly than hs-CRP, since no further laboratory acquisitions are necessary, which is especially relevant in regions where cost efficiency is of importance. Funding Acknowledgement Type of funding sources: None. Table 1. Kappa statisticFigure 1. Bland-Altman plot

Chest pain characteristics and their ability to predict NSTEMI according to gender and age in patients presenting with suspected ACS

Abstract Background The epidemiologic panorama of acute myocardial infarction (AMI) has changed during the past decades with a lower rate of ST elevation myocardial infarction (STEMI) and higher rate of non-ST elevation myocardial infarction (NSTEMI). Most studies on presenting symptoms in patients with AMI include high rates of STEMI patients and were performed during a time when high-sensitivity cardiac troponin assays (hs-Tn) were not available. Hence, our knowledge on typical symptoms and their ability to predict AMI may not apply to the majority of today's patients in the emergency departments (ERs). Purpose Report chest pain characteristics and additional symptoms in patients presenting with suspected acute coronary syndrome (ACS) without ST elevations in a contemporary cohort diagnosed with hs-Tn. Assess the risk of having an NSTEMI based on symptom characteristics for women, men and patients ≥ and <70 years of age and evaluate the strength of associations between symptom and gender or age category. Methods A total of 1506 patients >18 years admitted with suspected ACS without ST elevation were included in the WESTCOR study from Sept. 2015 to May 2019. Diagnoses were adjudicated by two independent cardiologists. Information about symptoms was retrospectively collected from electronic medical records. Odds ratios (OR) for NSTEMI were calculated for all symptoms, and logistic regression was used to assess the interaction between genders and age groups ≥ and <70 years of age. Results 66.8% of all patients presented with both typical location and character. More women than men presented with atypical location (9.4 vs 6.8%, p<0.001) while more men presented with atypical character (21.1 vs 17.9%, p=0.004). Women significantly more often than men reported radiating pain and typical additional symptoms (figure). Differences between age groups were most often non-significant. Both genders and age groups had significantly increased odds of NSTEMI if pain radiated to both arms, was triggered by physical activity or happened in the course of chest pain prodromes, see table. Men had significantly lower OR for AMI compared to women if pain was dependent of position, respiration or palpation (OR 0.17 vs 0.53, p-value for interaction 0.047). Younger patients had significantly lower OR for NSTEMI compared to older patients if pain radiated to the left arm (OR 0.73 vs 1.67, p-value for interaction 0.045) and higher OR if exertional chest pain had been present during the last week prior to admission (OR 4.08 vs 1.81, p-value for interaction 0.025). We did not find that women had higher risk of NSTEMI if they presented with atypical pain compared to men (OR 0.50 vs 0.72, not significant). Conclusion Radiation to both arms has the strongest predictive value for NSTEMI. We do not find that women or older patients have higher odds ratio for NSTEMI if they present with atypical symptoms. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Grieg Foundation Incidence of symptomsIncidence and OR for NSTEMI

High plasma levels of soluble LOX-1 portends poor survival in acute coronary syndromes beyond GRACE 2.0: a multicentre prospective cohort study

Abstract Background While inflammatory states and dyslipidemias confer a dismal prognosis following myocardial ischaemia, the role of the lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) which sits at the confluence of these conditions remains elusive. Given soluble LOX-1' (sLOX-1) pivotal role in inflammatory processes underlying atherosclerotic plaque progression, we sought to study its prognostic utility on the risk of adverse events in acute coronary syndromes (ACS). Purpose Hence, we aimed to investigate whether sLOX-1 is an independent predictor of all-cause death at one year beyond traditional and emerging risk factors for poor survival following ACS. Methods 2678 ACS patients were recruited in the prospective, multicentre SPUM-ACS trial, of which 2525 completed follow-up at one year. Major adverse cardiovascular events, including death from any cause, were adjudicated by an independent clinical endpoint committee. By employing high-sensitive enzyme-linked immunosorbent assay, sLOX-1 was assessed in the plasma at the time of presentation in ACS and age-matched chronic coronary syndrome (CCS) patients. Kaplan-Meier survival analysis and Cox proportional hazard regression models, adjusted for baseline variables and the GRACE 2.0 score, were used to study the predictive utility of sLOX-1. Results At the time of presentation, ACS patients, specifically those with ST-segment elevation ACS, had significantly elevated sLOX-1 levels as compared to patients with CCS (median, 35.40 vs. 2.00 pg/ml, P<0.0001). Patients in the upper sLOX-1 tertile were at heightened risk for both death from any cause (crude HR 1.785, 95% CI 1.083–2.941, P<0.05; adjusted HR 2.035, 95% CI 1.176–3.519, P<0.05) and CV death (crude HR 2.447, 95% CI 1.285–4.663, P<0.01; adjusted HR 2.383, 95% CI 1.206–4.710, P<0.05) compared to those in the first tertile. Importantly, sLOX-1 remained an independent predictor of all-cause death after adjustment for known risk factors of adverse outcome and the GRACE 2.0 score (adjusted + GRACE 2.0 HR 1.896, 95% CI 1.034–3.476, P<0.05). Conclusions Plasma sLOX-1 is elevated in ACS patients and predicts poor survival independent of both traditional and emerging risk factors and provides prognostic information beyond GRACE 2.0. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Swiss National Science FoundationFoundation for Cardiovascular Research - Zurich Heart House

New insights from the MESA study: increased high-sensitivity troponins as a cardiovascular risk factor.

The most recent high-sensitivity assays for troponins I and T (hs-TnI and hs-TnT) have made it possible to detect blood concentrations up to 10 times lower than previous assays, making troponins detectable even in asymptomatic subjects without manifest cardiovascular disease. For this reason, hs-Tn, initially introduced as markers of myocardial damage in an acute setting, have also become possible markers of subclinical myocardial damage in baseline conditions. In fact, recent evidence suggests that hs-TnT and hs-TnI predict the risk of future cardiovascular events also in the context of primary prevention, and offer incremental information when added to current risk stratification models. The different association highlighted with different outcome measures, such as coronary heart disease, atherosclerotic cardiovascular disease, heart failure, and death from all causes, seems to indicate that the risk observed in asymptomatic subjects with high levels of hs-Tn is an expression of subclinical damage secondary to multiple pathophysiological mechanisms, and not only to atherothrombosis. However, the ability of hs-TnT and hs-TnI (until now used interchangeably), to provide differential predictive information, and not redundant with respect to more traditional factors, remains to be definitively clarified, both for the purpose of predicting specific outcomes and for the implementation of specific preventive strategies. To date, evidences available allow us to hypothesize their role more as markers than as risk factors.

DMD/BMD - GENETICS: EP.113 Lack of correlation between DMD exon 2 duplication splicing choices and phenotype severity

Duchenne muscular dystrophy (DMD) is an X-linked disorder caused by mutations in the DMD gene. About 75% of DMD mutations are deletions or duplications while the remaining are small mutations. Exon 2 duplication is the most frequent duplication and is associated with variable phenotypes, ranging from mild to severe. We profiled the muscle biopsy splicing pattern of DMD exon 2 duplication in seven DMD patients (identified by MLPA) using the Agilent High Sensitivity assay. Four patients showed classical DMD phenotype, with loss of ambulation within 13-year-old while in the other three patients ambulation was lost >age 15. We found four different transcripts due to different splicing choices: the exon2-exon2 duplicated transcript (79%), the intron1-exon2-exon2 transcript, which incorporates an upstream region of intron 1, generating a premature stop codon (13%), a transcript with both exon 2 skipped (3%) and a transcript skipping one exon 2, which generates a normal messenger (6%), this last represented in all seven DMD muscles. We did not identify a phenotype-specific DMD splicing pattern in the seven exon 2 duplicated DMD patients. All DMD patients show a similar percentage of wild type transcript (6%), and the very low amount of the transcript skipping both exon 2 suggests that dystrophin rescue due to the alternative ATG translation start site in exon 5 may not play a major role in disease severity. Our results therefore indicate lack of correlation between DMD exon 2 duplication splicing choices and DMD phenotype.

Diagnostic patterns and stress testing trends after implementing high-sensitivity troponin assay.

High-sensitivity troponin T (hsTnT) testing was approved in the United States to better facilitate diagnosis of acute coronary syndrome (ACS). Although hsTnT has been widely studied internationally, the impact of hsTnT on discharge diagnoses and health care utilization within the United States is less known. We sought to evaluate the effects of implementing hsTnT on diagnosis patterns and stress testing utilization. We performed a retrospective cohort analysis consisting of patients with suspected ACS undergoing either conventional troponin I (n = 14,631) or hsTnT (n = 7237) testing between January 2016 and February 2019. Log-binomial regression with interrupted time series modeled diagnosis patterns, and logistic regression with segmented time trends modeled stress testing rates. Observed trends were compared with expected trends using average marginal effect (AME). Rates of acute myocardial infarction-related diagnoses were similar in the post-hsTnT period (AME, -0.6%; P = .065). Post hsTnT introduction, patients were more likely to receive a diagnosis of heart failure (2.1%; P < .001) or atrial fibrillation/flutter (0.9%; P < .001) and less likely to receive a diagnosis of hypertensive heart disease (-10.2%; P < .01) or hypertensive heart disease with chronic kidney disease (-3.7%; P < .001). Likelihood of receiving stress testing increased after hsTnT implementation (2.3%; P < .001). Variations in discharge diagnosis patterns and increases in stress test utilization were observed following hsTnT implementation. Hospitals can expect similar changes, which may have long-term implications on health care utilization, cost, and hospital reimbursement.

High Serum Uric Acid and High-Sensitivity C Reactive Protein Concentrations Predict Three-Year Cardiovascular Mortality in Patients Treated With Continuous Ambulatory Peritoneal Dialysis.

Aims: This study aims to access the predicting value of serum uric acid (UA) and high-sensitivity C reactive protein (hs-CRP) concentration on three-year cardiovascular-related mortality in patients performing continuous ambulatory peritoneal dialysis (CAPD).Methods: A total of267 CAPD patients [150 male (56.2%); mean age 48.93 ± 13.58 years] were included in our study. All patients had measured serum UA and hs-CRP concentration. A high-sensitivity particle-enhanced immunoturbidimetric assay determined serum hs-CRP; serum UA levels were determined using an enzymatic colorimetric assay. All patients were followed for three years to detect cardiovascular-related mortality by cardiologists and stroke specialists.Results: Mean serum UA level was 415.16 ± 84.28 µmol/L, 58.4% of patients had increased serum UA level. Median serum hs-CRP level was 2 (1-4) mg/L, 12.4% of patients had increased serum hs-CRP level. During 36 months of follow-up, 41 patients (15.4%) had cardiovascular-related mortality. The results of Cox proportional hazards regression showed that hypertension, diabetes, high serum UA and hs-CRP were risk factors that related to cardiovascular-related mortality (p<0.05). The receiver operating characteristic (ROC) curve and Kaplan-Meier analysis results showed that UA and hs-CRP level had predictive value for three-year cardiovascular-related mortality in CAPD patients [uric acid: area under the curve (AUC)=0.822; hs-CRP: AUC=0.834, p < 0.001].Conclusion: High serum UA and hs-CRP levels were predictive factors of cardiovascular-related mortality in CAPD patients.

Comparison of Perioperative High-Sensitive Troponin T and Troponin I Assays in Cardiac Surgery

Troponin measurements are among the standard parameters for monitoring perioperative myocardial ischaemia after cardiosurgical procedures. As high-sensitive assays continue to replace older analytic parameters with lower sensitivity, this study aimed to compare perioperative profiles of a high-sensitive troponin T assay (hsTnT, Roche Diagnostics, Mannheim, Germany) with a troponin I assay (sTnI, Siemens Healthcare Diagnostics, Eschborn, Germany). A total of 287 consecutive patients undergoing a typical spectrum of cardiac procedures from August 2017 to March 2018 monitored with the hsTnT assay were compared with a propensity-matched collective analysed with the sTnI assay. For side-by side comparison, the peak troponin (Tmax) values were scaled to a z-score distribution before comparison. Despite absolute postoperative hsTnT and sTnI values differing by an order of magnitude, parameters could be scaled to a common distribution with kernel density curves overlapping 92%. Both parameters showed equal behaviour in subgroup analyses regarding relevant perioperative factors, such as type of procedure, cross-clamping time, and type of cardioplegic solution. However, there were some differences regarding pre-existing renal impairment between both parameters. In both groups, renal failure patients with chronic kidney disease stages IV or V as well as patients on haemodialysis exhibited a marked Tmax increase of >100% compared with normal kidney function (hsTnT,+121%; 2,383.5 vs 1,078.8 ng/L; p=0.0006; and sTnI,+149%; 27.3 ng/mL vs 11.0 ng/mL; p=0.009). However, in patients with moderately impaired renal function, those in the hsTnT group, but not in the sTnI cohort, showed significantly increased Tmax values (CKD stages II or III, 1,233.5 ng/L [+14%] and 1,314.1 ng/L [+22%] vs 1,078.8 ng/L; p=0.01 and p=0.03). In these patients, the postoperative interval until Tmax was reached was also significantly increased (14.4 and 19.0 hrs vs 12.4 hrs for chronic kidney disease stages II and III; p=0.0038 and p<0.001), indicating a higher rate of accumulation in the hsTnT parameter. In the context of cardiac surgery, this study found that both parameters behaved in a similar manner under most relevant circumstances. Despite significant difference in the absolute serum concentration, hsTnT and sTnI can be scaled to virtually identical distributions. However, renal impairment did affect both parameters differently with troponin T but not troponin I, showing evidence of accumulation in moderately impaired renal disease.

The Relationship between the Tissue Expression of TLR2, TLR4, TLR5, and TLR7 and Systemic Inflammatory Responses in Colorectal Cancer Patients

Background: Colorectal cancer (CRC) is the third most commonly diagnosed malignancy globally. CRC patients with elevated plasma C-reactive protein (CRP) levels exhibit compromised prognoses. Toll-like receptors (TLRs), activating the innate and adaptive immune systems, may contribute to pro- and antitumorigenic inflammatory responses. We aimed to identify a possible link between local and systemic inflammatory responses in CRC patients by investigating the association between tissue TLRs and plasma CRP. Methods: Tissue expressions of TLR2, TLR4, TLR5, and TLR7 were assessed using immunohistochemistry of tissue microarray slides from 549 CRC patients surgically treated between 1998 and 2005. Blood samples were drawn preoperatively, centrifuged, aliquoted, and stored at −80°C until analysis. Plasma CRP was determined through high-sensitivity time-resolved immunofluorometric assay. We investigated the association of TLRs to clinicopathologic variables, plasma CRP, and survival. Results: High TLR2 expression (hazard ratio [HR] 0.59; 95% confidence interval [CI] 0.41–0.85; p = 0.005), high TLR5 expression (HR 0.60; 95% CI 0.45–0.83; p = 0.002), positive TLR7 expression (HR 0.49; 95% CI 0.33–0.72; p < 0.001), and low CRP (HR 1.48; 95% CI 1.08–2.11; p = 0.017) were associated with a better prognosis. A high TLR2 immunoexpression was associated with a better prognosis among low-CRP patients (HR 0.53; 95% CI 0.35–0.80; p = 0.002), high TLR4 expression among high-CRP patients (HR 2.04; 95% CI 1.04–4.00; p = 0.038), high TLR5 expression among low-CRP patients (HR 0.059; 95% CI 0.37–0.92; p = 0.021), and positive TLR7 expression among low-CRP patients (HR 0.53; 95% CI 0.28–1.00; p = 0.049). In multivariate analyses, no biomarkers emerged as significant independent variables. Conclusions: High tissue TLR2, TLR5, and TLR7 levels were associated with a better prognosis. Among low-CRP patients, those with high TLR2, TLR5, and TLR7 immunoexpressions exhibited a better prognosis. Among high CRP patients, a high TLR4 immunoexpression was associated with a better prognosis.

High-Sensitivity Assays for C-Reactive Protein as a Systemic Inflammatory Marker in Assessing Asthma

Asthma is a chronic inflammatory condition, and the main features include airway hyper-responsiveness and inflammation of the airway with the accumulation of inflammatory cells. Increased level of plasma fibrinogen and serum amyloid A suggests the involvement of systemic inflammation in asthma. C-reactive protein (CRP) is an acute-phase protein that produced mainly by hepatocytes and is an inflammatory marker. CRP levels monitoring is useful in the evaluation of early inflammation and efficacy of treatment in acute-phase illnesses. Several studies show that asthma alone can cause an increase in high-sensitivity CRP (hs-CRP) when compared with the healthy controls. Besides that, steroid-naïve patients have a higher mean value of hs-CRP levels compared with those on inhaled corticosteroid. Furthermore, studies have shown that an elevated hs-CRP level has a positive correlation with non-atopic asthma but not atopic asthma. Additionally, an increase in serum hs-CRP levels correlates with the severity of asthma. Therefore, serum hs-CRP is a useful surrogate marker to predict the severity of inflammation of the bronchus in asthma and assess the asthma status.

P–639 The role of chronic inflammation in polycystic ovarian syndrome – a systematic review and meta-analysis

Abstract Study question Is polycystic ovarian syndrome (PCOS) associated with chronic inflammation as determined by elevated serum C-reactive protein (CRP) level independent of obesity? Summary answer: Circulating CRP is moderately elevated in women with PCOS (independent of obesity), which is indicative of low-grade chronic inflammation. What is known already Although current literature associates polycystic ovarian syndrome (PCOS) with chronic inflammation, the evidence for this link remains inconclusive and its causal nature remains unclear. A systematic review and meta-analysis involving 31 studies was published on this topic in 2011 providing evidence for increased circulating CRP (96% higher than controls). However, since that review there have been over 100 published studies assessing CRP in PCOS women utilising more advanced CRP assays. Study design, size, duration This systematic review involved an extensive search of electronic databases for studies investigating CRP and other inflammatory makers in PCOS women from January 2000 to March 2020. Searched databases included PUBMED, EMBASE and MEDLINE, SCOPUS, DynaMed plus, TRIP, ScienceDirect and Cochrane Library. Inclusion criteria were using Rotterdam criteria for PCOS diagnosis, measuring CRP with high-sensitivity assay, matching/adjusting participants for BMI, and including drug naïve participants who were free from conditions that could affect inflammatory markers. Participants/materials, setting, methods The review included all studies comparing circulating CRP between women with and without PCOS. Articles’ quality and risk of bias were assessed using modified Newcastle-Ottawa scale. CRP data were extracted from eligible studies and entered into RevMan software for calculation of standardized mean difference (SMD) and 95% Confidence Interval (CI). Sensitive analysis was performed for high-quality studies providing data for non-obese participants. Main results and the role of chance The systematic review included 95 eligible studies (n = 10,074), of which 68 (n = 7991) were included in a meta-analysis. Sixty-two of the 95 studies reported significantly higher circulating CRP in PCOS women (n = 5235) versus controls (n = 4839). The remaining studies showed no statistically significant differences between the two groups after adjusting for BMI. Pooled analysis of 68 studies revealed significantly higher circulating CRP in PCOS women (SMD 1.26, 95%CI, 1.01, 1.52; z = 9.60; p = 0.00001; I²=96%). Sensitivity meta-analysis for non-obese women in 37 high-quality studies showed significantly higher circulating CRP in PCOS women versus controls (SMD 1.84, 95%CI, 1.40, 2.28; z = 8.19; p &amp;lt; 0.00001; I²=97%). Circulating TNF- α was measured in 13 studies, of which seven reported higher levels in PCOS women versus controls and six showed no difference. Circulating IL–6 was measured in 19 articles, of which eight reported significantly higher levels in PCOS women versus controls and 11 found no difference. Four studies (n = 512) reported increased white cell count in PCOS women (n = 323) compared with healthy controls (n = 189). Nine studies (n = 922) assessed circulating adiponectin, with seven showing significantly lower levels in PCOS women (n = 368) versus controls and one showing no difference. Meta-analysis of four of these studies (n = 355) revealed a SMD –1.48 (95% CI; –2.48,-.14). Limitations, reasons for caution High heterogeneity between studies and the small size of several studies are the main limitations. Heterogeneity is due to variation in laboratory methods used to measure CRP and variations between participants e.g. age, BMI and PCOS phenotypes. Sensitivity and sub-group analysis were performed to address this heterogeneity. Wider implications of the findings: Further research is required to understand the underlying molecular mechanisms and the pathophysiological role of chronic inflammation in PCOS. This could potentially identify targets for new treatments that could improve short- and long-term health problems associated with PCOS. Trial registration number N/A

C-reactive protein as a diagnostic and prognostic factor of endometrial cancer.

Endometrial cancer (EC) is the sixth most commonly occurring cancer in women and its morbidity and mortality are continuously increasing. Considering experience with different types of cancers, C-reactive protein (CRP) appears to be a promising diagnostic and prognostic factor. Aiming to investigate its potential in view of EC authors of this paper reviewed databases for metanalysis, randomized controlled trials and review articles. Studies indicate CRP > 3.33 mg/l correlates with the EC incidence with HR = 2.29 (p < 0.05). Moreover, High-sensitivity CRP assay allows to detect CRP in very low concentrations and distinguish patients with endometriosis, soft tissue sarcomas and possibly EC. Perioperational CRP, as well as its changes are independent prognostic factors for EC. However, CRP-to-albumin ratio as well as Glasgow Prognostic Score (GPS) have greater prognostic value that CRP alone. Additionally, CRP is possibly a mediator of carcinogenesis and cancer progression through activation of inter alia FcgRs/MAPK/ERK, FcgRs/IL-6/AKT/STAT3 and FcgRs/NF-κB/NLRP3 pathways.

Novel strategies for the early diagnosis of hepatitisB virus reactivation.

HepatitisB virus (HBV) reactivation under systemic chemotherapy or immunosuppressive therapy is a serious complication among HBV-resolved patients. Some medications, such as more than 2weeks of corticosteroid therapy, can influence HBV reactivation; therefore, screening tests that measure hepatitisB surface antigen (HBsAg), hepatitisB core antibody, and hepatitis B surface antibody before therapy are required. Additionally, because HBV reactivation has been reported in patients positive for HBsAg treated with immune checkpoint inhibitors (ICIs), the prophylactic administration of nucleos(t)ide analogues prior to administering ICIs is recommended for HBsAg-positive patients. Under these circumstances, highly sensitive novel biomarkers are expected to be used for the early diagnosis of HBV reactivation. A fully automated high-sensitivity HBsAg assay (detection limit: 5mIU/ml) by Lumipulse HBsAg-HQ, with 10-fold higher sensitivity than that of conventional assays, is currently used. Furthermore, ultra-sensitive HBsAg assays using a semi-automated immune complex transfer chemiluminescence enzyme immunoassay (ICT-CLEIA; detection limit: 0.5mIU/ml) have been developed. Recently, a fully automated, novel high-sensitivity hepatitisB core-related antigen assay (iTACT-HBcrAg; cut-off value: 2.1LogU/mL) has been developed and reported. The utility of ICT-CLEIA and iTACT-HBcrAg for the diagnosis of HBV reactivation appears comparable to the use of HBV DNA. In this review, we provide the latest information related to medications that influence HBV reactivation and recently developed novel biomarkers that predict and monitor HBV reactivation.

Evaluation of a new automated assay for high-sensitivity thyroglobulin measurement and comparison with two established high-sensitivity thyroglobulin assays

ObjectiveThyroglobulin (Tg) is an important tumor marker for therapy control and follow-up of differentiated thyroid carcinoma (DTC). Over the past decade, assays for highly sensitive Tg measurement have become increasingly established. We evaluated a newly developed high-sensitive Tg assay running on an automated platform (LIAISON® Tg II Gen assay, DiaSorin), with a limit of quantification of 0.10 ng/ml. Design and MethodsTg values of 166 sera from subjects without thyroid diseases and of more than 500 sera of well-defined DTC patients were determined with the new LIAISON® Tg II Gen assay and compared with two established assays (Elecsys® Tg II/Roche, and Medizym® Tg REM/Medipan). ResultsTg reference values from healthy subjects were up to 37.93 ng/ml (women) resp. 24.59 ng/ml (men) with the LIAISON® Tg II Gen assay. Tg values showed good correlations in healthy subjects and patients with active tumorous disease. In contrast, Tg values in the very low range from cured thyroidectomized patients were poorly comparable between the three assays, while clinical differences between the cohorts were correctly reflected by all assays. ConclusionsWith the new LIAISON® Tg II Gen assay, another automated assay standardized against the first International Reference Preparation CRM-457 for highly sensitive measurement of Tg values is available.

First molecular-based detection of SARS-CoV-2 virus in the field-collected houseflies

This is the first report of SARS-CoV-2 detection on field-collected Musca domestica housefly surface and tissue samples using the high-sensitive PCR assay which suggests the possible insect-borne transmission. The study was conducted in Shiraz city, southern Iran, in May and Jun 2020. Adult flies were sampled at the outdoor areas of two hospitals treating COVID-19 patients. Fly samples were first washed twice to remove the insect surface attached to SARS-CoV-2 virions. After that, the disinfected fly samples were homogenized. Fly surface washout and homogenate samples were tested using Taq Man real-time PCR assay for the SARS-CoV-2 virus. In a total of 156 houseflies, 75% of samples from the body washout samples were positive for SARS-CoV-2. Strikingly, 37% of the homogenized specimens were positive for the SARS-CoV-2, suggesting the possible infection of the insects or uptake of the virion to the insect metabolism. The other possibility is the houseflies up took the blood or blood fluids of the patients and the RNA of the SARS-CoV-2 survived in the insect body without replicating. Our preliminary findings suggest that the houseflies could transmit SARS-CoV-2 as a mechanical or biological vector especially during the warm seasons while increasing the population and activity of houseflies.

Impact of Osteoprotegerin and RANKL on Non-ST-segment Elevation Myocardial Infarction

Objective: Osteoprotogerin and receptor activator of nuclear factor kappa-B ligand (RANKL) formed an alliance that joining between bone remaking and vascular reforming. The aim of this study is to quantify the blood concentrations of osteoprotogerin and of RANKL in diabetic patients with myocardial infarction and to evaluate their relationship with other perilous factors in reference to healthy subjects. Methods: A total of 76 diabetic patients with myocardial infarction of non-ST-segment raising aged 50 to 60 years and their matched 60 healthy control aged 45 to 55 years were randomly selected from Al-yarmook Hospital and evaluated for inclusion in this case–control study. Blood levels of osteoprotogerin and RANKL were assessed using high-sensitive enzyme-linked immunosorbent assay. Results: The outcomes of this study elucidated increment in the blood concentrations of osteoprotogerin and RANKL in those patients. Apparently, significant positive correlation directed between osteoprotogerin level with age and onset of diabetes. Otherwise, lipid profile, and inflammatory markers exhibited no significant correlation with osteoprotogerin level. Conclusion: Upraised blood levels of osteoprotogerin and RANKL in diabetic patients with non-ST-segment raising myocardial infarction may be of a consequence of diabetic complication on vascular cell.

Implementation of a High-Sensitivity Troponin-I Assay in an Academic Medical Center: A Qualitative and Quantitative Assessment.

To describe the clinical impact and lessons learned through implementation of a high sensitivity troponin (hsTn) assay. hsTn assays have received regulatory approval for use in the United States, and healthcare facilities are beginning to adopt these new assays. Questions remain about how to implement them and what effect they may have on demand for cardiovascular services. We conducted a mixed-methods implementation science-based investigation of hsTn adoption at a single academic medical center. We designed the investigation based on the Consolidated Framework for Implementation Research, exploring clinicians' perspectives on intervention characteristics, inner setting, individual characteristics, and process of implementation domains. Focus groups were conducted with clinicians from multiple service lines. Participants reported that the new hsTn assay did not fundamentally change processes of care such as cardiology consultations or inpatient admissions. Implementation was facilitated by leveraging the electronic medical record to provide useful suggestions for hsTn management at the point-of-care. The use of case-based teaching was considered most effective. Areas of ongoing concern included management of high-risk patients, outpatient follow-up, and feasibility of accelerated diagnostic protocols for early discharge from the emergency department. A decrease in the number of hsTn assays ordered was observed; no change was noted for admissions, cardiology consultations, or noninvasive cardiac imaging. A comprehensive educational campaign, based on multidisciplinary collaboration can effectively prepare clinicians for implementation of hsTn. New hsTn assays may not have any substantial effect on acute management of patients with cardiac complaints.

Abstract 554: Aqueous humor as a liquid biopsy for uveal melanoma

Abstract Purpose: Metastatic Uveal Melanoma (UM) is usually fatal within one year of symptom onset. There are a variety of biomarkers that can stratify patients' metastatic risk, but identifying them requires intraocular tumor biopsy. Liquid biopsy offers a less invasive alterative without the risks of retinal detachment and intraocular hemorrhage. We investigated whether the aqueous humor (AH) has sufficient tumor-derived cell-free DNA (cfDNA) to function as a liquid biopsy for UM. Methods: This case series includes 12 AH samples from 7 eyes of 7 UM patients from whom AH was sampled during routine brachytherapy plaque placement and/or removal. Double stranded DNA (dsDNA), single stranded DNA (ssDNA), RNA, and microRNA (miRNA) were quantified with respective Qubit High Sensitivity Assay Kits (Thermo Fischer) for each sample. The lower limit of detection was 0.01 ng/µL for dsDNA, 0.05 ng/µL for ssDNA, 0.25 ng/µL for RNA, and 0.05 ng/µL for miRNA. CfDNA was then isolated and sequenced on an Illumina platform to assess genome-wide somatic copy number alterations (SCNAs). Results: Aqueous humor derived cfDNA was detected in all samples, ranging from 0.085-28.8 ng/µL (mean = 2.7 ng/µL). RNA was detected in 2 of 12 samples (mean = 1.6 ng/µL, range = 0.7-2.5 ng/µL), and miRNA was detected in 11 of 12 samples (mean = 1.7 ng/µL, range = 0.094-16.2 ng/µL). There was a significantly higher cfDNA concentration in post-radiation samples than pre-radiation samples, (median = 0.082 ng/µL in pre-radiation, 0.21 ng/µL in post-radiation, W = 1, z = -2.55, p &amp;lt; 0.05, Wilcoxon Signed-rank test). This finding was similar when comparing all nucleic acid concentrations (dsDNA, ssDNA, RNA, and miRNA) between pre- and post-radiation (median = 0.085 ng/µL in pre-radiation, 0.333 ng/µL in post-radiation, W = 1, z = -3.46, p = 0.00027). Confirmed UM genomic alterations of 6p gain, 6q loss, and 8q gain were identified in one post-radiation AH sample from an eye with an iridociliary body tumor. These SCNAs are characteristic of UM. No SCNAs were found in the AH from the pre-radiation sample in the same eye, or any of the other AH samples sequenced to date. Conclusions: The AH is a source of cfDNA in eyes with UM, with a higher yield of all nucleic acids detected after brachytherapy radiation treatment. UM associated SCNAs were identified in the AH of one eye with an iridociliary tumor after radiation only. We hypothesize this may be due to intratumoral necrosis from the radiation as well as the proximity of the primary tumor to the AH in the case where SCNAs were identified. These results represent the first time that UM SCNAs have been identified in cfDNA isolated from the AH, and this provides preliminary evidence that the AH can serve as a liquid biopsy for UM. Citation Format: Mary E. Kim, Liya Xu, Chen-Ching Peng, Peter Kuhn, James Hicks, Jesse L. Berry. Aqueous humor as a liquid biopsy for uveal melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 554.

Barriers to Successful Implementation of Precision Medicine to the Treatment of Refractory AML: Lessons Learned

Tremendous genomic heterogeneity has been reported for patients with acute myeloid leukemia (AML), as well as variability in gene expression. We have developed a custom high throughput drug sensitivity (HTS) assay enabling testing of ~150 drugs and combinations, both FDA approved and investigational, including chemotherapy agents and targeted inhibitors. We enrolled advanced relapsed/refractory AML patients (pts) on two successive trials, NCT01872819 “Treatment for Relapsed / Refractory AML Based on a High Throughput Drug Sensitivity Assay” and NCT NCT02551718 “Individualized Treatment for Relapsed/Refractory Acute Leukemia Based on Chemosensitivity and Genomics/Gene Expression Data.” The first trial enrolled 16 AML pts (3-5 prior regimens) of whom 14 received single agent study directed treatment, and the second trial (2-6 prior regimens) enrolled 25 AML pts of whom 14 received study directed therapy including drug combinations. We were able to choose chemotherapy drugs for all pts that had IC50's of ≤ 0.1 µM, or regimens that demonstrated synergy for drugs in combination. We have established feasibility as defined by the study, in that HTS assay results were reported at an average of 5.6 days (range 4-10), mutation analysis for 194 genes by MyAML™ reported in 12.5 days (range 9-17) with turnaround from receipt median 8 days (range 7-12) and treatment started at 7.8 (mean), 8 (median) days (range 4-11).In the first trial, 1 pt (5prior regimens), achieved complete remission with incomplete count recovery (CRi) with the single chosen drug, and 1 achieved CR, 1 CRi with subsequent regimens of additional drugs based on screening and published combinations. Median overall survival (OS) was 88 days for all patients, range 7 to 411. For the 2nd trial, where combinations were used, there were 2 CRs, 1 CRi and 3 partial responses. Median OS was 122 days, range 19-379. Of the patients in the 1st trial who had therapy that could have been directed by mutation analysis, there were 4 with FLT3, 1 KIT, 1 IDH2, 1 TP53, 1 FLT3+KIT, 2 FLT3+ IDH2 mutations (10/12 tested). For the 2nd trial there were 2 pts with FLT3D835, 2 TP53, 2 translocations involving FLT3, 1 IDH2 + FLT3-ITD, 1 FLT3-ITD + IDH1, 1 IDH1, 1 FLT3D839, 1 FLT3-ITD + TP53, 1 IDH2, 1 BCR-ABL (13/17 tested), and one patient received imatinib for BCR-ABL, 2 sorafenib for Flt3 mutations, and 1 with a TP53 mutation received decitabine. We had a number of logistical difficulties, including very advanced disease , poor performance status, inability to obtain the drugs with the lowest IC50's or as directed by mutations due to investigational status or lack of insurance approval, and inability to treat pts who returned home to their local physicians. We observed a higher response rate in pts who received drug combinations (8) vs. single agents (1). Although these were just feasibility trials, we also tried to compare their outcomes to a historical control group. We selected 2 matches for each of our pts, total of 50. They were matched to age, length of CR1, prior HCT, prior intense salvage and prior number of total salvages. One limitation was to find controls that had received ≥3 salvages like some of our studied population. Most of the patients in our clinical trial received single drug therapy (64 vs 24%) and non-intense therapy (4 vs 44%), when compared to our historical control group. Although these were very important treatment differences, the median OS did not differ statistically between both groups (88 vs 115 days, p: 0.327).We have gathered clinical data, and data on mutation analysis, gene expression, and drug sensitivity testing, that have been analyzed to determine correlations of specific features with drug resistance. Moreover, we have the ability to confirm functional drug sensitivity to the targeted inhibitors based on mutation data. All these data can contribute to future algorithms to assist in optimizing drug choices.In conclusion, our future iterations of this approach will include 1) only drug combinations, 2) study of pts with only 2 prior regimens, and 3) earlier incorporation of targeted inhibitors such as midostaurin and the new IDH2 inhibitor, enasidenib, into combination regimens. The current salvage options for relapsed/refractory AML have dismal results, as exhibited by our historical control group; only 10% were alive at 1 year. We will therefore pursue alternative approaches for this population, including the optimization of precision medicine methodology. DisclosuresWalter:ADC Therapeutics: Research Funding; Aptevo Therapeutics: Research Funding. Patay:Invivoscribe: Employment. Carson:Invivoscribe, Inc.: Employment. Radich:Amgen: Consultancy; Gilliad: Consultancy; Novartis: Consultancy, Other: lab contracts for bid and service assays; BMS: Consultancy; Ariad: Consultancy; Pfizer: Consultancy. Becker:GlycoMimetics, Inc.: Research Funding.