The Effect of Vaccine Type and SARS-CoV-2 Lineage on Commercial SARS-CoV-2 Serologic and Pseudotype Neutralization Assays in mRNA Vaccine Recipients

The use of anti-spike (S) serologic assays as surrogate measurements of SARS-CoV-2 vaccine induced immunity will be an important clinical and epidemiological tool. The characteristics of a commercially available anti-S antibody assay (Roche Elecsys anti-SARS-CoV-2 S) were evaluated in a cohort of vaccine recipients. Levels were correlated with pseudotype neutralizing antibodies (NAb) across SARS-CoV-2 variants. We recruited adults receiving a two-dose series of mRNA-1273 or BNT162b2 and collected serum at scheduled intervals up to 8 months post-first vaccination. Anti-S and NAb levels were measured, and correlation was evaluated by (i) vaccine type and (ii) SARS-CoV-2 variant (wild-type, Alpha, Beta, Gamma, and three constructs Day 146*, Day 152*, and RBM-2). Forty-six mRNA vaccine recipients were enrolled. mRNA-1273 vaccine recipients had higher peak anti-S and NAb levels compared with BNT162b2 (P < 0.001 for anti-S levels; P < 0.05 for NAb levels). When anti-S and NAb levels were compared, there was good correlation (all r values ≥ 0.85) in both BNT162b2 and mRNA-1273 vaccine recipients across all evaluated variants; however, these correlations were nonlinear in nature. Lower correlation was identified between anti-S and NAb for the Beta variant (r = 0.88) compared with the wild-type (WT) strain (r = 0.94). Finally, the degree of neutralizing activity at any given anti-S level was lower for each variant compared with that of the WT strain, (P < 0.001). Although the Roche anti-S assay correlates well with NAb levels, this association is affected by vaccine type and SARS-CoV-2 variant. These variables must be considered when interpreting anti-S levels. IMPORTANCE We evaluated anti-spike antibody concentrations in healthy mRNA vaccinated individuals and compared these concentrations to values obtained from pseudotype neutralization assays targeting SARS-CoV-2 variants of concern to determine how well anti-spike antibodies correlate with neutralizing titers, which have been used as a marker of immunity from COVID-19 infection. We found high peak anti-spike concentrations in these individuals, with significantly higher levels seen in mRNA-1273 vaccine recipients. When we compared anti-spike and pseudotype neuralization titers, we identified good correlation; however, this correlation was affected by both vaccine type and variant, illustrating the difficulty of applying a "one size fits all" approach to anti-spike result interpretation. Our results support CDC recommendations to discourage anti-spike antibody testing to assess for immunity after vaccination and cautions providers in their interpretations of these results as a surrogate of protection in COVID-vaccinated individuals.

Clinical Benefits of Direct-to-Definitive Testing for Monitoring Compliance in Pain Management

Background: The technical advantages of direct-to-definitive liquid chromatographytandem mass spectrometry (LC-MS/MS) urine testing for monitoring patient compliance in pain management are well known. However, the design and implementation of LC-MS/MS methods are more controversial, including factors such as determining appropriate cutoffs, specimen processing (e.g., specimen hydrolysis), reporting of qualitative and/or quantitative results, and test menu. Objectives: The objective of the research was to compare the clinical performance of our previous urine pain toxicology panel, a combination of immunoassay (IA) screens and LC-MS/MS, to our current pain toxicology panel, which features direct-to-definitive LC-MS/MS for 34 drugs and metabolites. Study Design: Six months of results from our previous pain toxicology panel were compared to 5.5 months of results from our current pain toxicology panel, enabling us to make conclusions regarding clinical performance. Setting: The research took place at Brigham and Women’s Hospital in Boston, MA. Methods: The percentage of false positive IA results was evaluated for our previous pain toxicology panel. The positivity rates for each drug and/or metabolite were calculated for both the previous and current panels, including rates of detection of both prescribed and illicit drugs. The turnaround time (TAT), direct and send-out costs associated with each approach, as well as projected cost savings were also determined. Results: False positive rates with IA ranged from 0% to 29%; the highest false positive rate was seen for 6-acetylmorphine (6-AM). The elimination of IA, addition of metabolites, and/or lowering of cutoffs increased the detection rate of 6-AM, benzoylecgonine (cocaine metabolite), fentanyl, morphine, and oxycodone. The ability to differentiate compliance from simulated compliance improved after eliminating specimen hydrolysis. The TAT improved significantly and projected yearly cost savings with the current panel was $95,003 (USD). In our opinion, qualitative results appeared sufficient to assess compliance in the majority of cases. Limitations: Our study was performed in a single academic center in a specific geographic region; therefore, our results may not be generalizable to other types of centers or regions. Conclusion: Direct-to-definitive LC-MS/MS testing has several clinical benefits, including reduction of false positive results, improved assessment of patient compliance, decreased TAT, and increased detection of drug use and abuse. Cost savings were also realized using this approach. Key words: Direct-to-definitive, LC-MS/MS, immunoassay, sensitivity, cost, pain management, turnaround time, patient compliance

Clinical Benefits of Direct-to-Definitive Testing for Monitoring Compliance in Pain Management

BACKGROUND

The technical advantages of direct-to-definitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) urine testing for monitoring patient compliance in pain management are well known. However, the design and implementation of LC-MS/MS methods are more controversial, including factors such as determining appropriate cutoffs, specimen processing (e.g., specimen hydrolysis), reporting of qualitative and/or quantitative results, and test menu.

OBJECTIVES

The objective of the research was to compare the clinical performance of our previous urine pain toxicology panel, a combination of immunoassay (IA) screens and LC-MS/MS, to our current pain toxicology panel, which features direct-to-definitive LC-MS/MS for 34 drugs and metabolites.

STUDY DESIGN

Six months of results from our previous pain toxicology panel were compared to 5.5 months of results from our current pain toxicology panel, enabling us to make conclusions regarding clinical performance.

SETTING

The research took place at Brigham and Women's Hospital in Boston, MA.

METHODS

The percentage of false positive IA results was evaluated for our previous pain toxicology panel. The positivity rates for each drug and/or metabolite were calculated for both the previous and current panels, including rates of detection of both prescribed and illicit drugs. The turnaround time (TAT), direct and send-out costs associated with each approach, as well as projected cost savings were also determined.

RESULTS

False positive rates with IA ranged from 0% to 29%; the highest false positive rate was seen for 6-acetylmorphine (6-AM). The elimination of IA, addition of metabolites, and/or lowering of cutoffs increased the detection rate of 6-AM, benzoylecgonine (cocaine metabolite), fentanyl, morphine, and oxycodone. The ability to differentiate compliance from simulated compliance improved after eliminating specimen hydrolysis. The TAT improved significantly and projected yearly cost savings with the current panel was $95,003 (USD). In our opinion, qualitative results appeared sufficient to assess compliance in the majority of cases.

LIMITATIONS

Our study was performed in a single academic center in a specific geographic region; therefore, our results may not be generalizable to other types of centers or regions.

CONCLUSION

Direct-to-definitive LC-MS/MS testing has several clinical benefits, including reduction of false positive results, improved assessment of patient compliance, decreased TAT, and increased detection of drug use and abuse. Cost savings were also realized using this approach.

KEY WORDS

Direct-to-definitive, LC-MS/MS, immunoassay, sensitivity, cost, pain management, turnaround time, patient compliance.

Immunoassay-Based Drug Tests Are Inadequately Sensitive for Medication Compliance Monitoring in Patients Treated for Chronic Pain

Background: Enzyme immunoassays (EIA) have notable limitations for monitoring therapeutic compliance in pain management. Chromatography coupled with mass spectrometry provides definitive results and superior sensitivity and specificity over traditional EIA testing. Objective: To analyze and compare the sensitivity of EIA results together with known prescriptions to liquid chromatography-tandem mass spectrometry (LC-MS/MS) for monitoring drug use (and abuse) in patients treated for chronic pain. Study Design: A total of 530 urine samples from patients being treated for chronic pain were studied. Setting: Pain management clinic in the United States. Methods: The samples were tested for a profile of chronic pain medications and illicit drugs with commercially available EIA kits followed by analysis with Agilent LC-MS/MS system. Results: The EIAs exhibited poor sensitivity and high rates of false negative results in the pain management setting. For example, 21% of EIA for opiates show false negative results. Mass spectrometry methods were more sensitive, detected a broader range of drugs and metabolites, and could detect non-prescribed drug use and simulations in compliance. Limitations: Patients do not always accurately report drug use information, and some drugs do not have EIA methods available for comparative purposes. Conclusions: Mass spectrometry is a more robust and reliable method for detection of drugs used in the pain management setting. Due to the extent of undisclosed use and abuse of medications and illicit drugs, LC-MS/MS testing is necessary for adequate and accurate drug detection. In addition, LC-MS/MS methods are superior in terms of sensitivity and number of compounds that can be screened, making this a better method for use in pain management. Key words: Pain management, enzyme immunoassays, mass spectrometry, urine drug testing, prescription status, compliance

Immunoassay-Based Drug Tests Are Inadequately Sensitive for Medication Compliance Monitoring in Patients Treated for Chronic Pain

BACKGROUND

Enzyme immunoassays (EIA) have notable limitations for monitoring therapeutic compliance in pain management. Chromatography coupled with mass spectrometry provides definitive results and superior sensitivity and specificity over traditional EIA testing.

OBJECTIVE

To analyze and compare the sensitivity of EIA results together with known prescriptions to liquid chromatography-tandem mass spectrometry (LC-MS/MS) for monitoring drug use (and abuse) in patients treated for chronic pain.

STUDY DESIGN

A total of 530 urine samples from patients being treated for chronic pain were studied.

SETTING

Pain management clinic in the United States.

METHODS

The samples were tested for a profile of chronic pain medications and illicit drugs with commercially available EIA kits followed by analysis with Agilent LC-MS/MS system.

RESULTS

The EIAs exhibited poor sensitivity and high rates of false negative results in the pain management setting. For example, 21% of EIA for opiates show false negative results. Mass spectrometry methods were more sensitive, detected a broader range of drugs and metabolites, and could detect non-prescribed drug use and simulations in compliance.

LIMITATIONS

Patients do not always accurately report drug use information, and some drugs do not have EIA methods available for comparative purposes.

CONCLUSIONS

Mass spectrometry is a more robust and reliable method for detection of drugs used in the pain management setting. Due to the extent of undisclosed use and abuse of medications and illicit drugs, LC-MS/MS testing is necessary for adequate and accurate drug detection. In addition, LC-MS/MS methods are superior in terms of sensitivity and number of compounds that can be screened, making this a better method for use in pain management. Key words: Pain management, enzyme immunoassays, mass spectrometry, urine drug testing, prescription status, compliance.

A negative ion source test facility

Progress is being made in the development of an Ion Source Test Facility (ISTF) by D-Pace Inc. in collaboration with Buckley Systems Ltd. in Auckland, NZ. The first phase of the ISTF is to be commissioned in October 2015 with the second phase being commissioned in March 2016. The facility will primarily be used for the development and the commercialization of ion sources. It will also be used to characterize and further develop various D-Pace Inc. beam diagnostic devices.

KIMS, CEDIA, and HS-CEDIA Immunoassays Are Inadequately Sensitive for Detection of Benzodiazepines in Urine from Patients Treated for Chronic Pain

Background: Patients treated for chronic pain may frequently undergo urine drug testing to monitor medication compliance and detect undisclosed prescribed or illicit drug use. Due to the increasing use and abuse of benzodiazepines, this class of medications is often included in drug screening panels. However, immunoassay-based methods lack the requisite sensitivity for detecting benzodiazepine use in this population primarily due to their poor cross-reactivity with several major urinary benzodiazepine metabolites. A High Sensitivity Cloned Enzyme Donor Immunoassay (HS-CEDIA), in which betaglucuronidase is added to the reagent, has been shown to perform better than traditional assays, but its performance in patients treated for chronic pain is not well characterized. Objectives: To determine the diagnostic accuracy of HS-CEDIA, as compared to the Cloned Enzyme Donor Immunoassay (CEDIA) and Kinetic Interaction of Microparticles in Solution (KIMS) screening immunoassays and liquid chromatography-tandem mass spectrometry (LC-MS/MS), for monitoring benzodiazepine use in patients treated for chronic pain. Study Design: A study of the diagnostic accuracy of urine benzodiazepine immunoassays. Setting: The study was conducted at an academic tertiary care hospital with a clinical laboratory that performs urine drug testing for monitoring medication compliance in pain management. Methods: A total of 299 urine specimens from patients treated for chronic pain were screened for the presence of benzodiazepines using the HS-CEDIA, CEDIA, and KIMS assays. The sensitivity and specificity of the screening assays were determined using the LC-MS/MS results as the reference method. Results: Of the 299 urine specimens tested, 141 (47%) confirmed positive for one or more of the benzodiazepines/metabolites by LC-MS/MS. All 3 screens were 100% specific with no false-positive results. The CEDIA and KIMS sensitivities were 55% (78/141) and 47% (66/141), respectively. Despite the relatively higher sensitivity of the HS-CEDIA screening assay (78%; 110/141), primarily due to increased detection of lorazepam, it still missed 22% (31/141) of benzodiazepine-positive urines. The KIMS, CEDIA, and HS-CEDIA assays yielded accuracies of 75%, 79%, and 90%, respectively, in comparison with LC-MS/MS. Limitations: This study was limited by its single-site location and the modest size of the urine samples utilized. Conclusions: While the HS-CEDIA provides higher sensitivity than the KIMS and CEDIA assays, it still missed an unacceptably high percentage of benzodiazepine-positive samples from patients treated for chronic pain. LC-MS/MS quantification with enzymatic sample pretreatment offers superior sensitivity and specificity for monitoring benzodiazepines in patients treated for chronic pain. Key words: High sensitivty immunoassay, benzodiazepine, beta-glucoronidase, pain management, compliance, LC-MS/MS, screening

KIMS, CEDIA, and HS-CEDIA immunoassays are inadequately sensitive for detection of benzodiazepines in urine from patients treated for chronic pain

BACKGROUND

Patients treated for chronic pain may frequently undergo urine drug testing to monitor medication compliance and detect undisclosed prescribed or illicit drug use. Due to the increasing use and abuse of benzodiazepines, this class of medications is often included in drug screening panels. However, immunoassay-based methods lack the requisite sensitivity for detecting benzodiazepine use in this population primarily due to their poor cross-reactivity with several major urinary benzodiazepine metabolites. A High Sensitivity Cloned Enzyme Donor Immunoassay (HS-CEDIA), in which beta-glucuronidase is added to the reagent, has been shown to perform better than traditional assays, but its performance in patients treated for chronic pain is not well characterized.

OBJECTIVES

To determine the diagnostic accuracy of HS-CEDIA, as compared to the Cloned Enzyme Donor Immunoassay (CEDIA) and Kinetic Interaction of Microparticles in Solution (KIMS) screening immunoassays and liquid chromatography-tandem mass spectrometry (LC-MS/MS), for monitoring benzodiazepine use in patients treated for chronic pain.

STUDY DESIGN

A study of the diagnostic accuracy of urine benzodiazepine immunoassays.

SETTING

The study was conducted at an academic tertiary care hospital with a clinical laboratory that performs urine drug testing for monitoring medication compliance in pain management.

METHODS

A total of 299 urine specimens from patients treated for chronic pain were screened for the presence of benzodiazepines using the HS-CEDIA, CEDIA, and KIMS assays. The sensitivity and specificity of the screening assays were determined using the LC-MS/MS results as the reference method.

RESULTS

Of the 299 urine specimens tested, 141 (47%) confirmed positive for one or more of the benzodiazepines/metabolites by LC-MS/MS. All 3 screens were 100% specific with no false-positive results. The CEDIA and KIMS sensitivities were 55% (78/141) and 47% (66/141), respectively. Despite the relatively higher sensitivity of the HS-CEDIA screening assay (78%; 110/141), primarily due to increased detection of lorazepam, it still missed 22% (31/141) of benzodiazepine-positive urines. The KIMS, CEDIA, and HS-CEDIA assays yielded accuracies of 75%, 79%, and 90%, respectively, in comparison with LC-MS/MS.

LIMITATIONS

This study was limited by its single-site location and the modest size of the urine samples utilized.

CONCLUSIONS

While the HS-CEDIA provides higher sensitivity than the KIMS and CEDIA assays, it still missed an unacceptably high percentage of benzodiazepine-positive samples from patients treated for chronic pain. LC-MS/MS quantification with enzymatic sample pretreatment offers superior sensitivity and specificity for monitoring benzodiazepines in patients treated for chronic pain.

Fast education: a comparison of teaching models for trauma sonography

This study's objective was to evaluate the peritoneal dialysis and mannequin simulator models for the hands-on portion of a 4-h focused abdominal sonography for trauma (FAST) course. After an introductory lecture about trauma sonography and practice on normal models, trainees were assigned randomly to two groups. They practiced FAST on one of the two simulator models. After the didactic and hands-on portions of the seminar, FAST interpretation testing revealed mean scores of 82% and 78% for the peritoneal dialysis and mannequin simulator groups, respectively (p = 0.95). Post-course surveys demonstrated mean satisfaction scores for peritoneal dialysis and mannequin simulator models of 3.85 and 3.25, respectively, on a 4-point Likert scale (p = 0.317). A FAST educational seminar, which provides both didactic and hands-on instruction, can be completed in 4 h; the hands-on instruction phase can incorporate both normal models and abnormal simulation models, such as the peritoneal dialysis model and the multimedia mannequin simulator.

Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes?

OBJECTIVE

To measure the ability of cardiac sonography and capnography to predict survival of cardiac arrest patients in the emergency department (ED).

METHODS

Nonconsecutive cardiac arrest patients prospectively underwent either cardiac ultrasonography alone or in conjunction with capnography during cardiopulmonary resuscitation at two community hospital EDs with emergency medicine residency programs. Cardiac ultrasonography was carried out using the subxiphoid view during pauses for central pulse evaluation and end-tidal carbon dioxide (ETCO(2)) levels were monitored by a mainstream capnograph. A post-resuscitation data collection form was completed by each of the participating clinicians in order to assess their impressions of the facility of performance and benefit of cardiac sonography during nontraumatic cardiac resuscitation.

RESULTS

One hundred two patients were enrolled over a 12-month period. All patients underwent cardiac sonographic evaluation, ranging from one to five scans, during the cardiac resuscitation. Fifty-three patients also had capnography measurements recorded. The presence of sonographically identified cardiac activity at any point during the resuscitation was associated with survival to hospital admission, 11/41 or 27%, in contrast to those without cardiac activity, 2/61 or 3% (p < 0.001). Higher median ETCO(2) levels, 35 torr, were associated with improved chances of survival than the median ETCO(2) levels for nonsurvivors, 13.7 torr (p < 0.01). The multivariate logistic regression model, which evaluated the combination of cardiac ultrasonography and capnography, was able to correctly classify 92.4% of the subjects; however, of the two diagnostic tests, only capnography was a significant predictor of survival. The stepwise logistic regression model, summarized by the area under the receiver operator curve of 0.9, furthermore demonstrated that capnography is an outstanding predictor of survival.

CONCLUSIONS

Both the sonographic detection of cardiac activity and ETCO(2) levels higher than 16 torr were significantly associated with survival from ED resuscitation; however, logistic regression analysis demonstrated that prediction of survival using capnography was not enhanced by the addition of cardiac sonography.

Effect of a single bout of acute exercise on plasma human immunodeficiency virus RNA levels

Acute exercise is known to activate the immune system and thus could lead to increased human immunodeficiency virus (HIV) replication. We sought to determine whether a single acute bout of exercise, similar to what people experience when starting an intensive exercise program, has a detrimental effect on plasma HIV RNA levels. Twenty-five patients with HIV infection performed one 15-min bout of acute exercise. Absolute neutrophil counts, serum creatine phosphokinase, and 72-h urinary 3-methylhistidine (a marker of muscle protein breakdown) were measured before and after the exercise, along with plasma HIV RNA levels. There were increases in neutrophil counts (P < 0.06), serum creatine phosphokinase (P < 0. 01), and urinary 3-methylhistidine (P < 0.01) in response to exercise, indicating a mild acute-phase response with muscle proteolysis. However, mean HIV RNA, which was elevated at baseline in 22 of the 25 subjects (mean of 4 x 10(5) +/- 0.7 x 10(5) copies/ml), did not increase during the week after exercise (P = 0. 12). Small changes in RNA were seen in the three subjects with initially undetectable HIV RNA, but the significance of these changes is unclear. Acute exercise does not have a deleterious effect on HIV replication in adults with high viral loads. Because regular exercise training has not been shown to activate the acute-phase response, the lack of increased viral loads in response to an acute exercise intervention suggests that exercise training is safe in people with HIV infection.

Impact of emergency medicine resident training in ultrasonography on ultrasound utilization

Training programs in bedside ultrasound for emergency physicians often encounter considerable resistance, partly because of concern that the number of radiology-interpreted studies ordered from the ED may decrease. This study attempted to determine the effect of instituting an ED training program in ultrasound on the ordering of formal studies from a department of radiology. This retrospective, computer-assisted review compared all abdominal sonograms ordered from the ED of a busy community hospital in the 3 years before introduction of an ultrasound training program (1992 through 1994) with those ordered in the 2 years after the program's inception (1995, 1996). The number of formal studies significantly increased after institution of the training program, both in terms of absolute numbers (annual mean 181 v 95, P < .001) and as a percentage of all outpatient sonograms ordered at the institution (9.8% v 5.1%, P < .001). Introduction of a teaching program in emergency ultrasound appears to increase utilization of formal ultrasound services, at least during the training period.

Paramedic interpretation of prehospital lead-II ST-segments

OBJECTIVE

To determine the reliability of ST-segment interpretation by paramedics from lead-II rhythm strips obtained in the prehospital setting.

DESIGN

Prospective, blinded study of 127 patients transported by an urban/rural emergency medical services system with complaints consistent with ischemic heart disease.

METHODS

Emergency department physicians asked emergency medical technician-paramedics (EMT-P) via radio to evaluate ST-segments for elevation or depression and grade it as "mild," "moderate," or "severe." Then, this rhythm strip was interpreted blindly by emergency physicians who also interpreted the lead-II obtained from a 12-lead electrocardiogram (ECG) obtained in the emergency department (ED). The field interpretation was compared with the subsequent readings and the final in-patient diagnosis using positive predictive value (PPV), negative predictive value (NPV), and the Kappa statistic. Markedly discrepant interpretations were analyzed separately.

RESULTS

Using physician interpretation as the reference standard, paramedic interpretation of the lead-II ST-segments obtained in the prehospital setting was correct (within +/- 1 gradation) in 113 out of 127 total cases (89%). Of 105 patients for whom final hospital diagnosis was available, the ST-segment on the rhythm strip obtained in the prehospital setting, had a positive predictive value of 74% and a negative predictive value of 85% for myocardial ischemia or myocardial infarction (MI) (p < 0.001, Kappa = 0.59). Discordant interpretations between the paramedics and emergency physicians often were related to a basic misunderstanding of rhythm strip morphology.

CONCLUSION

Field interpretation of ST-segments by paramedics is fairly accurate as judged both by emergency physicians and correlation with final patient outcome, but its clinical utility is unproved. A small but clinically significant number of outliers, consisting of markedly discrepant false positives, reflects paramedic uncertainty in identifying the deviations of the ST-segment.

Use of indomethacin suppositories in the prophylaxis of recurrent ureteral colic

To determine the effects of indomethacin suppositories in the relief of acute colic and prevention of recurrent colic, we instituted a prospective double-blind, placebo-controlled protocol. Patients were randomized to receive either 50 mg. indomethacin or placebo suppositories every 8 hours and all patients received prescriptions for supplemental narcotics to be used on an as needed basis. Relief of colic was assessed by counting the total number of supplemental narcotics used by each patient per 24 hours during the study period, which was defined as until passage of the calculus or 5 days. There were 41 patients entered into the study protocol and complete followup was available for 26. Mean calculus size was 3.4 mm. in the indomethacin group versus 3.1 mm. in the placebo group. All 13 patients in the control group had recurrent episodes of colic and 8 of these 13 had more than 1 recurrent episode. Five patients in the placebo group required admission to the hospital for control of pain. In contrast, only 4 of the 13 patients in the treatment group had colic and only 1 had more than 1 episode of colic. No patient in the active drug group required admission to the hospital for control of pain. Over-all the ratio of supplemental narcotic used by the placebo group versus the indomethacin group was 7.6:1 (p less than 0.005). The mean interval time to passage of the calculus was slightly lower in the indomethacin group (89 versus 82 hours) but this difference was not statistically significant (p greater than 0.10). Our data strongly support the use of indomethacin suppositories in the prevention of recurrent colic secondary to ureteral calculi.