To assess factors associated with serologic response to the coronavirus 2019 (COVID-19) booster vaccine in patients with autoimmune rheumatic diseases treated with rituximab (RTX) who were previously ...serologically unresponsive to the initial vaccine series.
A retrospective chart review of patients treated with RTX who failed to demonstrate a serologic response to the first SARS-CoV-2 vaccination series and subsequently received an mRNA vaccine booster was performed. Serologic response ≥ 4 weeks after the booster was the primary outcome. Fisher exact tests,
tests, and Wilcoxon rank-sum tests were used for comparisons.
In 31 patients who were previously seronegative, 68% seroconverted following a booster of the COVID-19 vaccine. B cell reconstitution was significantly different between those with positive (median 1.79, IQR 0.65-3.00) and negative (median 0, IQR 0-0) serologic responses to the booster. The days from last RTX dose were also statistically different among seroconverters (median 301, IQR 251-368) vs nonseroconverters (median 188, IQR 169-245). Demographic characteristics were not associated with serologic positivity. Positive predictive value of B cell presence was 90.9% (95% CI 70.8-98.9) and negative predictive value was 100% (95% CI 59-100) for serologic response to the mRNA booster vaccine. Positive predictive value of time ≥ 6 months from last RTX dose to booster was 78.3% (95% CI 56.3-92.5) and the negative predictive value was 62.5% (95% CI 24.5-91.5).
Detectable B cells and longer time from last RTX exposure were associated with the development of anti-SARS-CoV-2 spike protein antibodies following the booster vaccine. These findings should be considered in timing boosters in patients treated with RTX.
IntroductionImmune checkpoint inhibitors (ICI) are a novel cancer therapeutic that have been successful in treating advanced malignancies; however, they also cause immune-related adverse events ...(irAE). Given that some irAE are clinically similar to traditional autoimmune diseases, autoantibodies have been suggested as possible biomarkers of irAE. However, there are very little data on autoantibody investigation prior to ICI. Our aim was to determine if specific baseline autoantibodies were associated with irAE and see if changes in autoantibody concentration corresponded with irAE development.MethodsThis study used data from an oncologic clinical trial of adaptive dosing combination ICI therapy in patients with advanced melanoma. Plasma was collected at baseline and 6 weeks after ICI initiation and tested in a microarray of 120 autoantigens commonly associated with autoimmune disease, as well as antinuclear antibody (ANA), rheumatoid factor (RF), and anti-cyclic citrullinated peptide antibody (anti-CCP). Autoantibody concentrations were compared between patients experiencing an organ-specific event versus not. Heatmaps, volcano plots and hierarchical clustering were used to determine autoantibody concentration differences among irAE patient clusters as defined by signal intensity of autoantibodies. Kaplan-Meier curves were created and a log-rank test was performed to assess differences in survival.ResultsThe microarray analysis demonstrated that patients who experienced specific irAE had fewer differentially expressed autoantibodies at baseline than those that did not have those specific irAE, and a greater fold change (FC) in antibody concentration from baseline to 6 weeks corresponded with specific irAE development. However, no autoantibodies were identified as being predictive of specific events. Time to first irAE was less than 6 weeks in 69% of patients, and these patients had less autoantibodies at baseline. Considering ANA, RF and CCP autoantibodies, there were no significant differences between the seropositive and seronegative patients in irAE development, severity, timing or survival.ConclusionPatients with low autoantibody concentrations at baseline as well as a greater FC in autoantibody concentration over 6 weeks developed more distinct organ-specific irAE. This may suggest differences in the balance of cellular immunity and humoral pathways that are relevant in the pathogenesis of irAE, though further investigation is needed.
•Autoimmune patients and rheumatologists face an unprecedented challenge during the COVID-19 pandemic and are changing medication practices in response.•About half of US rheumatologists believe ...COVID-19 risk may be heightened in rheumatic disease patients, regardless of their immunosuppressive medications.•There were significant differences in the management of biologics, steroids and NSAIDs in response to COVID-19 reported by rheumatologists in areas with a high case burden, compared to those in less affected areas.
To investigate the perceptions and behaviors of rheumatologists in the United States (US) regarding the risk of COVID-19 for their autoimmune patients and the subsequent management of immunosuppressive and anti-inflammatory medications.
We administered an online survey to a convenience sample of rheumatologists in the US from 4/8/20-5/4/20 via social media and group emails. Survey respondents provided demographic information such as, age, gender, state of practice, and practice type. We asked questions about COVID-19 risk in rheumatic patients, as well as their medication management during the pandemic. We conducted descriptive analysis and Multivariable regression models.
271 respondents completed the survey nationally. 48% of respondents either agreed or strongly agreed with the statement “Patients with rheumatic diseases are at a higher risk of COVID-19 irrespective of their immunosuppressive medications”. 50% disagreed or strongly disagreed with the statement “The pandemic has led you to reduce the use/dosage/frequency of biologics”, while 56% agreed or strongly agreed with the statement “The pandemic has led you to reduce the use/dosage/frequency of steroids”. A third of respondents indicated that at least 10% of their patients had self-discontinued or reduced at least one immunosuppressive medication to mitigate their risk of COVID-19. Responses to these questions as well as to questions regarding NSAID prescription patterns were significantly different in the Northeast region of US compared to other regions.
In this national sample of rheumatologists, there are variations regarding perceptions of patients’ risk of COVID-19, and how to manage medications such as NSAIDs, biologics and steroids during the pandemic. These variations are more pronounced in geographical areas where COVID-19 disease burden was high.
Few published articles have focused on identifying the gaps in care that follow a malnutrition diagnosis and their effects on length of stay (LOS) and 90-day readmission. We hypothesized that length ...of stay and readmission were associated with these gaps in care.
Two registered dietitians retrospectively reviewed charts of 229 adult malnourished patients admitted to a medicine unit to determine their system level gap in care: communication, test delay, or discharge planning. In this secondary analysis, both readmission and length of stay were regressed on each gap in care.
Any system level gap was associated with a greater length of stay (β: 1.48, 95% CI: 1.15-1.91) and specifically the gap related to procedure/testing (β: 2.01, 95% CI: 1.62-2.47) resulted in a two-fold increase in length of stay. There was no association between 90-day readmission and any of the gaps in care.
There was a strong association between those who had any gap in their care and increased length of stay. Mitigating gaps in care may decrease length of stay and, in turn, result in less risk of infection and could potentially lead to reduced healthcare costs.
Over 18 million adults have initiated life-saving antiretroviral therapy (ART) in resource-poor settings; however, mortality and lost-to-follow-up rates continue to be high among patients in their ...first year after treatment start. Clinical decision tools are needed to identify patients at high risk for poor outcomes in order to provide individualized risk assessment and intervention. This study aimed to develop and externally validate risk prediction tools that estimate the probability of dying or of being lost to follow-up (LTF) during the year after starting ART.
We used a derivation cohort of 7,031 adults age 15-70 years initiating ART from 2007 to 2013 at 6 clinics in Haiti; 242 (3.5%) had documented death and 1,521 (21.6%) were LTF at 1 year after starting ART. The following routinely collected data were used as predictors in two logistic regression models (one to predict death and another to predict LTF): age, gender, weight, CD4 count, WHO Stage, and diagnosis of tuberculosis (TB). The validation cohort consisted of 1,835 adults initiating ART at a different HIV clinic in Haiti during 2012. We assessed model discrimination by measuring the C-statistic, and measured model calibration by how closely the predicted probabilities approximated actual probabilities of the two outcomes. We derived a nomogram and a point-based risk score from the predictive models.
The model predicting death within the year after starting ART had a C-statistic of 0.75 (95% CI 0.74 to 0.81). There was no evidence for significant overfitting and the predictions were well calibrated. The strongest predictors of 1-year mortality were male gender, low weight, low CD4 count, advanced WHO stage, and the absence of TB. In the validation cohort, the C-statistic was 0.69 (95% CI 0.59 to 0.77). A point-based risk score for death had a C-statistic 0.73 (95% CI 0.69 to 0.76) and categorizes patients as low risk (<2% risk of death), average risk (3-4%), and high-risk (8-10%) and very high-risk (14-19%) with likelihood ratios to be used in settings where the baseline risk is different from our study population. The model predicting LTF did not discriminate well (C-statistic 0.59).
A simple risk-score using routinely collected data can predict 1-year mortality after ART initiation for HIV-positive adults in Haiti. However, predicting lost to follow-up using routinely collected data was not as successful. The next step is to assess whether use of this risk score can identify patients who need tailored services to reduce mortality in resource-poor settings such as Haiti.
ObjectiveTo assess the association between time-varying depressive symptoms with all-cause and cause-specific mortality.DesignThe REGARDS (Reasons for Geographic and Racial Differences in Stroke) is ...a national, population-based longitudinal study conducted from 2003 to 2007.SettingGeneral continental US communities.Participants29 491 black and white US adults ≥45 years randomly sampled within race–sex–geographical strata.ExposureElevated depressive symptoms (Centre for Epidemiologic Studies Depression (CES-D) 4≥4) measured at baseline and on average 5 and 7 years later.Main outcome measuresCox proportional hazard regression models assessed cancer, non-cardiovascular (cardiovascular disease (CVD)), CVD and all-cause mortality.ResultsThe average age was 64.9 years; 55% were women; 41% black; 11.0% had elevated depressive symptoms; 54% had poor, fair or good health. Time-varying depressive symptoms were significantly associated with non-CVD (adjusted HR (aHR)=1.29, 95% CI 1.16 to 1.44) and all-cause (aHR=1.24, 95% CI 1.14 to 1.39), but not cancer (aHR=1.15, 95% CI 0.96 to 1.38) or CVD (aHR=1.13, 95% CI 0.98 to 1.32) death adjusting for demographics, chronic clinical diseases, behavioural risk factors and physiological factors. Depressive symptoms were related to all-cause (aHR=1.48, 95% CI 1.27 to 1.78), CVD (aHR=1.37, 95% CI 0.99 to 1.91), non-CVD (aHR=1.54, 95% CI 1.24 to 1.92) and cancer (aHR=1.36, 95% CI 0.97 to 1.91) death in those who reported excellent or very good health. The analyses of the association between one measure of baseline depressive symptoms and mortality analyses yielded similar results.ConclusionsTime-varying depressive symptoms confer an increased risk for all-cause mortality, CVD, non-CVD death and cancer death, particularly in those with excellent or very good health. These findings may have implications for timely treatment, regardless of health status.
Within the United States, alternative tobacco product (ATP) and varies by geographic region, gender and age. Few articles have been published on the usage of these products among the lesbian, gay, ...bisexual, transgender or queer (LGBTQ) population. A web-based anonymous survey administered through Google Forms, was used to collect data on current tobacco usage, knowledge and beliefs from adult heterosexuals, homosexuals, bisexuals and transgendered persons residing in New York City from May 2014 to July 2014. Sixty-four individuals completed the survey; 30 were heterosexual and 32 identified as either lesbian, gay, bisexual, transgender or queer. Heterosexuals were found to have tried cigarettes, on average, almost a year before the LGBTQ respondents. Social networks were influential to LGBTQ respondents for an introduction to smoking; 48.00% were introduced by friends, 28.00% by family, 12.00% by a significant other and 9.09% by someone else. For heterosexuals, 73.68% reported that friends introduced them to smoking. More heterosexuals reported trying hookah (N = 10), snus (N = 4) and roll your own cigarettes (N = 5). On average respondents knew of eight different tobacco products, regardless of sexual identity. To our knowledge, we present for the first time a comparison of people who tried, current and former users of ATPs, beliefs and knowledge about ATPs, and sources of knowledge of ATPs by sexual identity from NYC. More research is needed to examine the impact of social networks and the upcoming FDA regulations on ATPs have on the overall prevalence of usage among the LGBTQ community.
ObjectiveThere is emerging evidence that COVID-19 disproportionately affects people from racial/ethnic minority and low socioeconomic status (SES) groups. Many physicians across the globe are ...changing practice patterns in response to the COVID-19 pandemic. We sought to examine the practice changes among rheumatologists and what they perceive the impact to be on their most vulnerable patients.MethodsWe administered an online survey to a convenience sample of rheumatologists worldwide during the initial height of the pandemic (between 8 April and 4 May 2020) via social media and group emails. We surveyed rheumatologists about their opinions regarding patients from low SES and racial/ethnic minority groups in the context of the COVID-19 pandemic. Mainly, what their specific concerns were, including the challenges of medication access; and about specific social factors (health literacy, poverty, food insecurity, access to telehealth video) that may be complicating the management of rheumatologic conditions during this time.Results548 rheumatologists responded from 64 countries and shared concerns of food insecurity, low health literacy, poverty and factors that preclude social distancing such as working and dense housing conditions among their patients. Although 82% of rheumatologists had switched to telehealth video, 17% of respondents estimated that about a quarter of their patients did not have access to telehealth video, especially those from below the poverty line. The majority of respondents believed these vulnerable patients, from racial/ethnic minorities and from low SES groups, would do worse, in terms of morbidity and mortality, during the pandemic.ConclusionIn this sample of rheumatologists from 64 countries, there is a clear shift in practice to telehealth video consultations and widespread concern for socially and economically vulnerable patients with rheumatic disease.
We report patient outcomes after antiretroviral therapy (ART) initiation in a network of HIV facilities in Haiti, including temporal trends and differences across clinics, during the expansion of HIV ...services in the country.
We assessed outcomes at 12 months after ART initiation (baseline) using routinely collected data on adults (≥15 years) in 11 HIV facilities from July 2007-December 2013. Outcomes include death (ascertained from medical records), lost to follow-up (LTF) defined as no visit > 365 days from ART initiation, and retention defined as being alive and attending care ≥ 365 days from ART initiation. Outcomes were compared across calendar year of ART initiation and across facilities. Risk factors for death and LTF were assessed using Cox proportional hazards and competing risk regression models.
Cumulatively, 9,718 adults initiated ART with median age 37 years (IQR 30-46). Median CD4 count was 254 cells/uL (IQR 139-350). Twelve months after ART initiation, 4.4% (95% CI 4.0-4.8) of patients died, 21.7% (95% CI 20.9-22.6) were LTF, and 73.9% (95% CI 73.0-74.8) were retained in care. Twelve-month mortality decreased from 13.8% among adults who started ART in 2007 to 4.4% in 2013 (p<0.001). Twelve-month LTF after ART start was 29.2% in 2007, 18.7% in 2008, and increased to 30.1% in 2013 (p<0.001). Overall, twelve-month retention after ART start did not change over time but varied widely across facilities from 61.1% to 86.5%.
Expansion of HIV services across Haiti has been successful with increasing numbers of patients initiating ART and decreasing twelve-month mortality rates. However, overall retention has not improved, despite differences across facilities, suggesting additional strategies to improve engagement in care are needed.
Gordonia infections in humans are rare and usually affect immunocompromised patients. We present the first case of Gordonia araii infection associated with a medical device in an immunocompetent ...patient. Sequencing was required for conclusive identification. We compared our case to the 16 Gordonia species-associated medical device infections reported to date.
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