Prospective Evaluation of Coronavirus Disease 2019 (COVID-19) Vaccine Responses Across a Broad Spectrum of Immunocompromising Conditions: the COVID-19 Vaccination in the Immunocompromised Study (COVICS)

BACKGROUND

We studied humoral responses after coronavirus disease 2019 (COVID-19) vaccination across varying causes of immunodeficiency.

METHODS

Prospective study of fully vaccinated immunocompromised adults (solid organ transplant [SOT], hematologic malignancy, solid cancers, autoimmune conditions, human immunodeficiency virus [HIV]) versus nonimmunocompromised healthcare workers (HCWs). The primary outcome was the proportion with a reactive test (seropositive) for immunoglobulin G to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) receptor-binding domain. Secondary outcomes were comparisons of antibody levels and their correlation with pseudovirus neutralization titers. Stepwise logistic regression was used to identify factors associated with seropositivity.

RESULTS

A total of 1271 participants enrolled: 1099 immunocompromised and 172 HCW. Compared with HCW (92.4% seropositive), seropositivity was lower among participants with SOT (30.7%), hematological malignancies (50.0%), autoimmune conditions (79.1%), solid tumors (78.7%), and HIV (79.8%) (P < .01). Factors associated with poor seropositivity included age, greater immunosuppression, time since vaccination, anti-CD20 monoclonal antibodies, and vaccination with BNT162b2 (Pfizer) or adenovirus vector vaccines versus messenger RNA (mRNA)-1273 (Moderna). mRNA-1273 was associated with higher antibody levels than BNT162b2 or adenovirus vector vaccines after adjusting for time since vaccination, age, and underlying condition. Antibody levels were strongly correlated with pseudovirus neutralization titers (Spearman r = 0.89, P < .0001), but in seropositive participants with intermediate antibody levels, neutralization titers were significantly lower in immunocompromised individuals versus HCW.

CONCLUSIONS

Antibody responses to COVID-19 vaccines were lowest among SOT and anti-CD20 monoclonal recipients, and recipients of vaccines other than mRNA-1273. Among those with intermediate antibody levels, pseudovirus neutralization titers were lower in immunocompromised patients than HCWs. Additional SARS-CoV-2 preventive approaches are needed for immunocompromised persons, which may need to be tailored to the cause of immunodeficiency.

Innervation and nerve injections of the lumbar spine of the horse: a cadaveric study

REASONS FOR PERFORMING STUDY

The distal limb innervation of the horse has been studied extensively to allow use of local anaesthetic techniques to detect the origin of pain in lameness. However, the innervation of the lumbar spine has so far been poorly described and a more precise description may assist clinicians to localise back pain in the horse.

OBJECTIVES

To gain better knowledge of the innervation of the lumbar spine and identify salient anatomical features that might be used for diagnostic and therapeutic ultrasound guided injections.

METHODS

The spines of 8 mature horses were dissected. Branches of the dorsal rami were followed and their anatomical relationship, with articular facets, interspinous structures and muscles, noted. The spines of 3 other horses were sectioned transversely and dissected to identify ultrasonographic landmarks of the nerves. Six other spines were used to assess the accuracy of ultrasound guided injections of the nerves with blue dye.

RESULTS

Gross dissections confirmed the dual segmental innervation of the articular facets. Each lumbar articular facet of 2 lumbar vertebrae was innervated by the medial branch of the dorsal ramus exiting from the intervertebral foramen between those vertebrae, but also by the branch originating of the dorsal ramus cranial to it. The medial branch divided into 2 nerves before exiting the intertransverse space and has salient anatomical landmarks which could be identified ultrasonographically. The ultrasound guided injection technique appeared to be of an accuracy that would be clinically useful.

CONCLUSION

The results identified that the salient anatomical features of the medial branch of the dorsal ramus, as described in the present study, can be used as landmarks for reliable ultrasound-guided injection.

POTENTIAL RELEVANCE

This study has a clear clinical relevance for development of diagnostic and therapeutic injection techniques of the lumbar spine in the horse.

Observer variation in the interpretation of intra-arterial angiograms and the risk of inappropriate decisions about carotid endarterectomy

OBJECTIVE

To determine how often observer variation in the interpretation of intra-arterial angiograms might alter the decision whether or not to refer patients for carotid surgery.

METHODS

A prospective study was carried out in a consecutive series of 99 patients with transient ischaemic attacks and minor strokes. Interpretable angiographic films were available for 179 carotid artery bifurcations. Stenosis of the internal carotid artery was measured using mm scales, independently by three different radiologists (A, B, and C), using the European Carotid Surgery Trial method.

RESULTS

An analysis of the grouped data showed good to moderate agreement by kappa statistics for radiologists A v B, B v C, and A v C of 0.68, 0.60, and 0.70 respectively. The mean absolute difference in the estimate of stenosis by each of the different radiologists (interobserver variation) was 9.5% and for each radiologist on two separate occasions (intraobserver variation) 8.4%. The degree of observer error was smallest among severely stenosed arteries. Although the absolute differences were small, "clinically important" differences which could change the treatment recommended from surgery to no surgery (or vice versa) occurred between radiologists A and B, B and C, and A and C in: seven (3.9%), six (3.4%), and 11 (6.1%) vessels respectively.

CONCLUSIONS

Because observer variation affects all of the imaging methods (Doppler, duplex, contrast arteriography, and MR angiography) used to select patients with transient ischaemic attack and stroke, these findings are likely to be widely relevant. Any centre assessing patients with cerebrovascular disease will need to implement strict quality control measures in the interpretation of angiograms (and other vascular imaging procedures) to minimise observer error and thereby reduce the number of inappropriate decisions made to refer for carotid artery surgery or not.

A prospective study of "undiagnosed" isolated myelopathy: II. Value of magnetic resonance imaging, evoked potentials and CSF analysis

We aimed to determine the sensitivity of available "diagnostic" tests in detecting subclinical abnormalities characteristic of multiple sclerosis (MS) in patients with unexplained isolated myelopathy, and any relationship between test results and level of disability. The trial investigations were carried out in 69 prospectively selected patients with acute or chronic noncompressive myelopathies. Magnetic resonance scans were the most sensitive individual tests, revealing asymptomatic brain lesions in 51 patients (74%, C.I. 64-84). An abnormal IgG/albumin ratio (IgG/A) was present in 29 (42%, C.I. 30-54), oligoclonal bands (OCB) in 27 (39%, C.I. 17-39) and abnormal evoked potentials (EP) (visual and/or auditory brain stem) in 19 cases (28%, C.I. 17-39). OCB and abnormal EP were found significantly less often than in control patients with clinically definite MS (CDMS) and significantly more often than in patients with myelopathy due to other conditions. The number of anatomical brain areas with lesions on magnetic resonance imaging (MRI) was significantly associated with CSF abnormalities; abnormal EP were correlated with abnormal MRI and elevated CSF immunoglobulins. Clinical classifications, age, symptom duration, disability levels and genetic factors did not appear to influence the prevalence of abnormal MRI or CSF. For the exclusion of compressive and structural diseases of the spinal cord, myelography has been superceded by cervical and thoracic MRI. In addition, MRI of the brain is the investigation of choice in patients with myelopathies that remain unexplained after spinal MRI. However, whether used alone or in combination with other tests, the specificity and predictive value of brain MRI abnormalities for the risk of developing MS, as well as the associated "false positive" rates, remain to be defined by long-term follow-up of prospectively ascertained and representative cases.

The incidence of first Hickman catheter-related infection and predictors of catheter removal in cancer patients

OBJECTIVE

To describe the incidence and types of first Hickman catheter-related infection (HCRI) in cancer patients and to identify indicators for catheter removal.

DESIGN

Retrospective cohort study.

SETTING

A regional, tertiary, referral cancer center and its supportive care university teaching hospital.

PATIENTS AND METHODS

A retrospective review was conducted of 316 consecutive adult oncology patients who underwent Hickman catheter placement from 1986 to 1990 at a regional oncology center. HCRI was determined on the basis of clinical information incriminating the Hickman catheter as the source of infection. Patient characteristics and data about HCRIs (exit site cellulitis, tunnel infection with concomitant exit site cellulitis, bloodstream infection, and exit site cellulitis with bloodstream infection) were abstracted from patient medical records. Subsequently, univariate and multivariate analyses for the risk of HCRI and catheter removal were completed.

RESULTS

The incidence of first HCRI was 5.98 infections per 1,000 catheter days. Overall, 156 (49%) of 316 patients developed their first HCRI prior to catheter removal. The median time to HCRI was 90 days. Male gender (P = .0004) and hematologic malignancy (P = .0001) emerged as significant risk factors for HCRI in the univariate analysis. A cox model verified that male gender (P = .02) and hematologic malignancy (P = .004) were associated with an enhanced risk of HCRI. There were 35 exit site infections (23%), three infections of the tunnel and the exit site (2%), 80 bloodstream infections (51%), and another 38 bloodstream infections with concomitant exist site infections (24%). The incidence of bloodstream infection was 3.05 per 1,000 catheter days. Gram-positive pathogens outnumbered gram-negatives and fungi, with Staphylococcus epidermidis being most common. Fifty (32%) of 156 HCRIs resulted in catheter removal. Predictors of Hickman catheter removal in the univariate analysis were bloodstream infection (P = .046) and pathogen type (P = .006). Multiple regression analysis suggested that having a gram-negative (P = .014) or fungal (P = .057) pathogen was the most important factor for catheter removal.

CONCLUSIONS

These data suggest that first HCRIs occur more commonly in male patients with hematologic malignancies than in patients with solid tumors. The removal of Hickman catheters in oncology patients probably is predicated on the causative pathogen, but further investigations are necessary to delineate this issue.

Retention of wooden foreign bodies in the orbit

Two cases of retention of wooden foreign bodies in the orbit are presented. Both patients had a draining fistula. A brain abscess developed in one and a foreign body granuloma in the other. In both cases computerized tomography was very helpful in localizing the foreign bodies and the sequelae. In such cases a subperiosteal surgical approach provides good exposure and minimizes the damage to the orbital contents. A high degree of suspicion of penetration of the orbit is essential in tree branch injuries of the eyelids.

An eighteenth-century amputation scene in the men's operating theatre of old St Thomas's Hospital

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The importance of peripheral vasoconstriction in influencing body temperatures and the part played by certain environmental factors: the effect of inhaled gases

Core and peripheral temperatures have been studied in 88 dogs of mixed breeds anaesthetized with pentobarbitone. Hyperventilation with cold, dry oxygen was associated with a decrease in peripheral temperature, whilst normoventilation was without effect.

Observations on peripheral and central temperatures with particular reference to the occurrence of vasoconstriction

The importance is emphasized of the inadequacy of the term 'body temperature', but that both core temperature and the peripheral temperature must be considered. The assessment of vasoconstriction is informative, and advantage should be taken of the exact information that can be provided by an electro-thermometer as opposed, for example, to a touch of the hand. The core temperature is taken from the rectum, the nasopharynx or tympanic membrane, and the peripheral temperature from the great toe. If the peripheral temperature falls the loss of body heat is prevented and the core temperature rises. If this is not understood or not recognized misguided attempts may be made to try to reduce the raised central temperature by cooling the skin. This can result in a further rise of central temperature. The recognition of peripheral vasoconstriction enables a proper assessment to be made of its basic cause and of the necessary treatment. The most important cause is hypovolaemia from blood loss and a detailed account is given of how this should be recognized, especially by a study of the gradient between central and peripheral temperatures. Such studies should be a routine in any severe illness, whether medical or surgical, in which circulatory deterioration is likely, especially after major operations or injuries. Study of the temperature of the heel (hindfoot) as well as of the toe (forefoot) can indicate a selective shutdown of peripheral circulation that reveals an especially critical circulatory state.

The importance of environmental conditions, especially temperature, in the operating room and intensive care ward

Although most patients are essentially well enough to be able to resist or to adapt to unfavourable ambient conditions, this may not be so with an ill patient or one who is having or has had a serious operation. The climatic conditions necessary in the operating room to give an optimal environment are discussed. These are second in importance only to control of infectivity. Air-conditioning in operating suites should be obligatory; there is even official acceptance of this. Earlier recommendations that the operating room should be heated to up to 80 degree F (27-9 degree C) are obsolete. The temperature most favoured by surgeons is 18-5-21 degree C; some prefer a range of 21-22 degre C. The critical ambient temperature desirable is 21 degree C. For infants and children this may be increased up to 24 degree C. It is difficult or impossible to achieve climatic conditions in the operating room that are acceptable to all. The needs of the patient are of special importance and are largely neglected; he alone is unable to speak for himself. The disposition of air inlets in the operating room is fully discussed. Climatic conditions in the intensive care unit are of great importance and are discussed. The need for full air-conditioning is absolute although this is often ignored. The delivery of conditioned air within the intensive care unit is also fully presented, especially the need to avoid direct chilling of the patient. The advantages of horizontal laminar air flow are presented.

Hypovolaemia and phaeochromocytoma

The state of shock which frequently follows removal of a phaeochromocytoma is due to the hypovolaemia resulting from prolonged excessive secretion of vasoconstrictor substances and should be treated with intravenous fluids. The gradient between central and peripheral temperatures provides a reliable guide to the hypovolaemic state. Two illustrative cases are described.

Long-term results after closed mitral valvotomy

This paper is an analysis of the experiences of the author with patients under-going closed mitral valvotomy between 1948 and December 1963, and thus represents a follow-up of at least 10 years. Five hundred and seventy-one of 618 patients survived operation; the mortality rate of 7.6% is much higher than pertains at present. It includes the early pioneer days when many very ill patients were operated on. There were only five deaths in the most recent 400 consecutive cases. The mortality should be low today. A detailed follow-up shows that many patients are completely cured of their mitral stenosis: of 168 patients alive longer than 11 years, 41 survived for 11 to 15 years, 67 for 16 to 20 years and 60 for over 20 years. Restenosis was diagnosed in 128 patients (22.4%) and 93 of them had a second operation. When the valve is severely damaged, especially when it is regurgitant, the results are not as good and valve excision and replacement are often needed, but valvotomy for pure mitral stenosis can give excellent and lasting results.

Long-term degenerative changes in aortic segment homografts, with particular reference to calcification

The object of this article is to present observations derived from a long-term follow-up (over a period of 8-17 years) of a personal series of aortic segment homografts from which certain important information arises. It will be shown that in those grafts prepared and preserved in a `fresh' state, calcification has not occurred or has been trivial, whereas in 20 cases in which the graft has been prepared by freeze-drying, calcification is absent in only four, i.e., 21%. Nineteen of these 20 have been traced up to date; only one is so far missing. In spite of calcification the functional result has remained excellent; in all, the graft was used to replace a segment of aorta resected for aneurysm or for coarctation. The high incidence of aortic wall calcification must assume clinical significance in relation to aortic valve homografting. This procedure is now well established and it is important to consider the future of the valve homograft, especially as most grafts are being prepared by freeze-drying. By analogy from observations on the rate of homografting of aortic segments, calcification is likely to occur at least in that portion of the aortic wall which carries the valve cusps. Impairment of function of the cusps or their involvement in the calcific process seems likely.