Cellular mechanisms associated with sub-optimal immune responses to SARS-CoV-2 bivalent booster vaccination in patients with Multiple Myeloma

BACKGROUND

The real-world impact of bivalent vaccines for wild type (WA.1) and Omicron variant (BA.5) is largely unknown in immunocompromised patients with Multiple Myeloma (MM). We characterize the humoral and cellular immune responses in patients with MM before and after receiving the bivalent booster, including neutralizing assays to identify patterns associated with continuing vulnerability to current variants (XBB1.16, EG5) in the current post-pandemic era.

METHODS

We studied the humoral and cellular immune responses before and after bivalent booster immunization in 48 MM patients. Spike binding IgG antibody levels were measured by SARS-CoV-2 spike binding ELISA and neutralization capacity was assessed by a SARS-CoV-2 multi-cycle microneutralization assays to assess inhibition of live virus. We measured spike specific T-cell function using the QuantiFERON SARS-CoV-2 (Qiagen) assay as well as flow-cytometry based T-cell. In a subset of 38 patients, high-dimensional flow cytometry was performed to identify immune cell subsets associated with lack of humoral antibodies.

FINDINGS

We find that bivalent vaccination provides significant boost in protection to the omicron variant in our MM patients, in a treatment specific manner. MM patients remain vulnerable to newer variants with mutations in the spike portion. Anti-CD38 and anti-BCMA therapies affect the immune machinery needed to produce antibodies.

INTERPRETATION

Our study highlights varying immune responses observed in MM patients after receiving bivalent COVID-19 vaccination. Specifically, a subgroup of MM patients undergoing anti-CD38 and anti-BCMA therapy experience impairment in immune cells such DCs, B cells, NK cells and TFH cells, leading to an inability to generate adequate humoral and cellular responses to vaccination.

FUNDING

National Cancer Institute (National Institutes of Health), National Institute of Allergy and Infectious Diseases (National Institutes of Health), NCI Serological Sciences Network for COVID-19 (SeroNet) and The Icahn School of Medicine at Mount Sinai.

SARS-CoV-2 Antibody Response among Women Infected during Pregnancy

OBJECTIVES

Novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus has been declared a pandemic by the World Health Organization as of March 11, 2020. Pregnant women naturally have a reduced immune system due to immunological changes and decreased lung capacity due to respiratory adaptations, making them more susceptible to coronavirus complications. Within the Mount Sinai Health system, more than 15,000 deliveries are performed annually. We began to care for pregnant women with known COVID-19 infections in late March of 2020. In early April 2020, a policy was implemented to perform universal COVID-19 testing for all women planning to deliver within the Mount Sinai Health system. We examined the antibody response of postpartum women who delivered at Mount Sinai Hospital with a SARS-CoV-2 infection between the study intervals during March 15, 2020, through April 30, 2020.

STUDY DESIGN

This was a prospective observational study examining the immune response of pregnant women who delivered at Mount Sinai Hospital with a polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection. Women with a SARS-CoV-2 infection were contacted via phone to discuss participation in the study. Patients who consented were scheduled for a phlebotomy visit to assess their antibody titer levels to COVID-19. The COVID-19 enzyme-linked immunosorbent assay (ELISA) immunoglobulin (Ig)-G antibody test was used to evaluate the patients' antibody titers. The assay detects IgG antibodies for the detection of IgG seroconversion in patients following a known recent SARS-CoV-2 infection.

RESULTS

A total of 120 patients were identified with a documented SARS-CoV-2 infection who delivered within the prespecified time frame. Of those patients, 25 women agreed to participate and were included. Of them, 64.00% were Caucasian with a mean age of 35 years. The mean body mass index (BMI) was 30 kg/m² and the majority of patients had commercial insurance (88.00%). The majority of women were asymptomatic for COVID-19 at the time of admission (80.00%) and the average gestational age of delivery and diagnosis of COVID-19 was 39 weeks' gestation. The later the gestational age at the time of diagnosis, the lower the antibody titer response. When examining the interval from diagnosis to antibody titer analysis, patients with the highest titers (2,880) tended to have a shorter interval between their COVID-19 diagnosis and the time at which the titer level was drawn. Patients with symptoms on admission had similar antibody titer levels when compared with women who were asymptomatic.

CONCLUSION

The antibody response among women infected with COVID-19 during pregnancy appears to be greater when the patients are diagnosed at an earlier gestational age.

KEY POINTS

· COVID-19 antibody status appears to be greater when diagnosed at an earlier gestational age.. · Asymptomatic and symptomatic pregnant women had similar antibody responses.. · Patients with the highest titers tended to have a shorter interval between their COVID-19 diagnoses..

Mission, Organization and Future Direction of the Serological Sciences Network for COVID-19 (SeroNet) Epidemiologic Cohort Studies

Global efforts are needed to elucidate the epidemiology of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the underlying cause of coronavirus disease 2019 (COVID-19) including seroprevalence, risk factors and long-term sequelae, as well as immune responses following vaccination across populations and the social dimensions of prevention and treatment strategies. In the U.S., the National Cancer Institute in partnership with the National Institute of Allergy and Infectious Diseases, established the SARS-CoV-2 Serological Sciences Network (SeroNet) as the nation’s largest coordinated effort to study COVID-19. The network is comprised of multidisciplinary researchers bridging gaps and fostering collaborations between immunologists, epidemiologists, virologists, clinicians and clinical laboratories, social and behavioral scientists, policy makers, data scientists, and community members. In total, 49 institutions form the SeroNet consortium to study individuals with cancer, autoimmune disease, inflammatory bowel diseases, cardiovascular diseases, HIV, transplant recipients, as well as otherwise healthy pregnant women, children, college students, and high-risk occupational workers (including health care workers and first responders). Several studies focus on underrepresented populations, including ethnic minorities and rural communities. To support integrative data analyses across SeroNet studies, efforts are underway to define common data elements for standardized serology measurements, cellular and molecular assays, self-reported data, treatment, and clinical outcomes. In this paper, we discuss the overarching framework for SeroNet epidemiology studies, critical research questions under investigation, and data accessibility for the worldwide scientific community. Lessons learned will help inform preparedness and responsiveness to future emerging diseases.

The Serological Sciences Network (SeroNet) for COVID-19: Depth and Breadth of Serology Assays and Plans for Assay Harmonization

Background

In October 2020, the National Cancer Institute (NCI) Serological Sciences Network (SeroNet) was established to study the immune response to COVID-19, and "to develop, validate, improve, and implement serological testing and associated technologies." SeroNet is comprised of 25 participating research institutions partnering with the Frederick National Laboratory for Cancer Research (FNLCR) and the SeroNet Coordinating Center. Since its inception, SeroNet has supported collaborative development and sharing of COVID-19 serological assay procedures and has set forth plans for assay harmonization.

Methods

To facilitate collaboration and procedure sharing, a detailed survey was sent to collate comprehensive assay details and performance metrics on COVID-19 serological assays within SeroNet. In addition, FNLCR established a protocol to calibrate SeroNet serological assays to reference standards, such as the U.S. SARS-CoV-2 serology standard reference material and First WHO International Standard (IS) for anti-SARS-CoV-2 immunoglobulin (20/136), to facilitate harmonization of assay reporting units and cross-comparison of study data.

Results

SeroNet institutions reported development of a total of 27 ELISA methods, 13 multiplex assays, 9 neutralization assays, and use of 12 different commercial serological methods. FNLCR developed a standardized protocol for SeroNet institutions to calibrate these diverse serological assays to reference standards.

Conclusions

SeroNet institutions have established a diverse array of COVID-19 serological assays to study the immune response to SARS-CoV-2 virus and vaccines. Calibration of SeroNet serological assays to harmonize results reporting will facilitate future pooled data analyses and study cross-comparisons.

The success of behavioral economics in improving patient retention within an intensive primary care practice

Background

A minority of the U.S. population comprises a majority of health care expenses. Health system interventions for high-cost populations aim to improve patient outcomes while reducing costly over-utilization. Missed and inconsistent appointments are associated with poor patient outcomes and increased health care utilization. PEAK Health— Mount Sinai’s intensive primary care clinic for high-cost patients— employed a novel behavioral economics-based intervention to reduce the rate of missed appointments at the practice. Behavioral economics has accomplished numerous successes across the health care field; the effect of a clinic-based behavioral economics intervention on reducing missed appointments has yet to be assessed.

Methods

This was a single-arm, pre-post trial conducted over 1 year involving all active patients at PEAK Health. The intervention consisted of: a) clinic signage, and b) appointment reminder cards containing behavioral economics messaging designed to increase the likelihood patients would complete their subsequent visit; appointment cards (t1) were transitioned to an identical EMR template (t2) at 6 months to boost provider utilization. The primary objective, the success of scheduled appointments, was assessed with visit adherence: the proportion of successful over all scheduled appointments, excluding those cancelled or rescheduled. The secondary objective, the consistency of appointments, was assessed with a 2-month visit constancy rate: the percentage of patients with at least one successful visit every 2 months for 1 year. Both metrics were assessed via a χ² analysis and together define patient retention.

Results

The visit adherence rate increased from 74.7% at baseline to 76.5% (p = .22) during t1 and 78.0% (p = .03) during t2. The 2-month visit constancy rate increased from 59.5% at baseline to 74.3% (p = .01) post-intervention.

Conclusions

A low-resource, clinic-based behavioral economics intervention was capable of improving patient retention within a traditionally high-cost population. A renewed focus on patient retention— employing the metrics described here— could bolster chronic care efforts and significantly improve the outcomes of high-cost programs by reducing the deleterious effects of missed and inconsistent appointments.

Neutralizing Antibody Responses in COVID-19 Convalescent Sera

Passive transfer of antibodies from COVID-19 convalescent patients is being used as an experimental treatment for eligible patients with SARS-CoV-2 infections. The United States Food and Drug Administration's (FDA) guidelines for convalescent plasma initially recommended target antibody titers of 160. We evaluated SARS-CoV-2 neutralizing antibodies in sera from recovered COVID-19 patients using plaque reduction neutralization tests (PRNT) at moderate (PRNT50) and high (PRNT90) stringency thresholds. We found that neutralizing activity significantly increased with time post symptom onset (PSO), reaching a peak at 31-35 days PSO. At this point, the number of sera having neutralizing titers of at least 160 was approximately 93% (PRNT50) and approximately 54% (PRNT90). Sera with high SARS-CoV-2 antibody levels (>960 enzyme-linked immunosorbent assay titers) showed maximal activity, but not all high-titer sera contained neutralizing antibody at FDA recommended levels, particularly at high stringency. These results underscore the value of serum characterization for neutralization activity.

COVID-19: Staging of a New Disease

Coronavirus disease 2019 (COVID-19), like cancer, is a complex disease with clinical phases of progression. Initially conceptualized as a respiratory disease, COVID-19 is increasingly recognized as a multi-organ and heterogeneous illness. Disease staging is a method for measuring the progression and severity of an illness using objective clinical and molecular criteria. Integral to cancer staging is "metastasis," defined as the spread of a disease-producing agent, including neoplastic cells and pathogens such as certain viruses, from the primary site to distinct anatomic locations. Staging provides valuable frameworks and benchmarks for clinical decision-making in patient management, improved prognostication, and evidence-based treatment selection.

Robust neutralizing antibodies to SARS-CoV-2 infection persist for months

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a global pandemic with millions infected and more than 1 million fatalities. Questions regarding the robustness, functionality, and longevity of the antibody response to the virus remain unanswered. Here, on the basis of a dataset of 30,082 individuals screened at Mount Sinai Health System in New York City, we report that the vast majority of infected individuals with mild-to-moderate COVID-19 experience robust immunoglobulin G antibody responses against the viral spike protein. We also show that titers are relatively stable for at least a period of about 5 months and that anti-spike binding titers significantly correlate with neutralization of authentic SARS-CoV-2. Our data suggest that more than 90% of seroconverters make detectable neutralizing antibody responses. These titers remain relatively stable for several months after infection.

Empanelment in a Resident Teaching Practice: A Cornerstone to Improving Resident Outpatient Education and Patient Care

BACKGROUND

Improving continuity is challenging in residency training practices. Studies have shown that empanelment enables high-performing primary care and is foundational to improve accountability and continuity.

OBJECTIVE

An empanelment process was created in a large, urban, residency training practice as an effective approach to enhancing continuity among residents and their patients.

METHODS

In 2016, we formed an empanelment committee that included stakeholders from the department of medicine, the internal medicine residency program, and hospital and IT leadership. This committee set goal panel sizes, selected an empanelment algorithm, determined which patients needed re-empanelment, and facilitated medical record integration. Empanelment was followed and reassessed quarterly for 2 years. We measured anticipated visit demand using visits in the prior year and continuity using the continuity for physician formula.

RESULTS

Of 18 495 active patients in July 2016, 8411 (45%) were assigned a new PCP in the empanelment process. At baseline, panel sizes and expected visit demand were highly variable among residents (from 40 to 107 and 120 to 480, respectively). Empanelment led to more equivalent panel sizes and expected visit demand across same year residents (eg, PGY-3: 80-100 and 320-440, respectively). Continuity for all PCPs in the practice improved from 63% before empanelment to over 80% after empanelment, and improved from 55% to 72% for individual residents.

CONCLUSIONS

In a large and complex practice environment, we were able to empanel resident clinic patients to improve continuity and maintain it over 2 years.

Managing Pain in Chronically Ill Homebound Patients Through Home-Based Primary and Palliative Care

BACKGROUND:

Many older adults are homebound due to chronic illness and suffer from significant symptoms, including pain. Home-based primary and palliative care (HBPC), which provides interdisciplinary medical and psychosocial care for this population, has been shown to significantly reduce symptom burden. However, little is known about how pain is managed in the homebound.

OBJECTIVE:

This article describes pain management for chronically, ill homebound adults in a model, urban HBPC program.

DESIGN/MEASUREMENTS:

This was a prospective observational cohort study of newly enrolled HBPC patients, who completed a baseline Edmonton Symptom Assessment System (ESAS) survey during the initial HBPC visit (N = 86). Baseline pain burden was captured by ESAS and pain severity was categorized as none, mild, or moderate-severe. All pain-related assessments and treatments over a 6-month period were categorized by medication type and titration, referrals to outside providers, procedures, and equipment.

RESULTS:

At baseline, 55% of the study population had no pain, 18% had mild pain, and 27% had moderate-severe pain. For those with moderate-severe pain at baseline (n = 23), prescriptions for pharmacological treatments for pain, such as opiates and acetaminophen, increased during the study period from 48% to 57% and 52% to 91%, respectively. Nonpharmacological interventions, including referrals to outside providers such as physical therapy, procedures, and equipment for pain management, were also common and 67% of the study population received a service referral during the follow-up period.

CONCLUSIONS:

Pharmacological and nonpharmacological treatments are widely used in the setting of HBPC to treat the pain of homebound, older adults.

Hospital at Home-Plus: A Platform of Facility-Based Care

OBJECTIVES

To describe the evolution of a hospital at home (HaH) program to a HaH with a 30-day posthospitalization transition period (HaH-Plus) and results of a retrospective review of cases.

DESIGN

After launching HaH-Plus, we used the same interdisciplinary clinical team to provide acute home-based care for a broader range of home-based acute-level services than originally conceived in the Hospital at Home model. These included a palliative care unit at home (PCUaH), an observation unit at home (OUaH), a post-acute care rehabilitation at home (RaH), and a program for the hospital averse - those patients needing to be in the hospital but who refuse.

SETTING

Urban health system.

PARTICIPANTS

Individuals 18 years or older residing in specified catchment area with Medicare fee-for-service or accepted Medicare/Medicaid Advantage plans requiring facility-based care.

INTERVENTION

Provision of facility-based acute-level care at home to 685 participants.

MEASUREMENTS

Length of stay, readmission, and mortality.

RESULTS

HaH-Plus cared for 685 individuals. The PCUaH had the oldest participants (mean age 87), and all groups were predominantly female and dually eligible for Medicare and Medicaid. Diagnoses and length of stay were similar in all groups except that those in RaH had a larger group of diagnoses, than those accepted in to HaH-Plus and those in OUaH had a shorter stay. Rate of readmission was highest for RaH (19%). Mortality during the active treatment episode was highest for PCUaH and hospital averse as compared to HaH-Plus, OUaH and RaH.

CONCLUSION

Providing a broader range of facility-based care in the home has significant advantages for patients and increases the scalability of HaH. Developing a spectrum of services was possible by leveraging a robust, 24-hour HaH team. Community- and home-based care could become a greater part of the U.S. healthcare system if a platform of HaH services along with advances in technology and payment models were developed. J Am Geriatr Soc 67:596-602, 2019.

Teaching Home-Based Primary Care

Despite the growing homebound population and the development of innovative models of care that work to bring care to people in their homes, home visits are not a routine part of education for many healthcare providers. This manuscript describes the experience of Mount Sinai Visiting Doctors teaching home-based primary care to learners of various disciplines and reports the results of a survey performed to assess trainee experience. Mount Sinai Visiting Doctors is the largest academic home-based primary care program in the country and trainees of various disciplines have nearly 1,700 contact days annually of directly supervised clinical teaching. In order to improve trainee education and meet our practice needs, trainees: 1) independently conduct urgent visits, 2) carry longitudinal panels of homebound patients, and 3) perform subspecialist consultations. Mount Sinai Visiting Doctors has exposed thousands of trainees to home-based primary care in the past 20 years and trainees report positive reviews of their experiences. As the need to train future providers in home-based primary care grows, we will be challenged to provide trainees with adequate exposure to multidisciplinary teams and to teach about the importance of continuity of care.

Predictors of Place of Death of Individuals in a Home-Based Primary and Palliative Care Program

OBJECTIVES

To investigate factors associated with place of death of individuals in the Mount Sinai Visiting Doctors Program (MSVD).

DESIGN

A retrospective chart review was performed of all MSVD participants who died in 2012 to assess predictors of place of death in the last month of life.

SETTING

MSVD, a home-based primary and palliative care program in New York.

PARTICIPANTS

MSVD participants who were discharged from the program because of death between January 2012 and December 2012 and died at home, in inpatient hospice, or in the hospital (N = 183).

MEASUREMENTS

Electronic medical records were reviewed to collect information on demographic characteristics, physician visits, and end-of-life conversations.

RESULTS

Of 183 participants, 103 (56%) died at home, approximately twice the national average; 28 (15%) died in inpatient hospice; and 52 (28%) died in the hospital. Bivariate analyses showed that participants who were white, aged 90 and older, non-Medicaid, or had a recorded preference for place of death were more likely to die outside the hospital. Diagnoses and living situation were not significantly associated with place of death. Multivariate logistic regression analysis showed no statistical association between place of death and home visits in the last month of life (odds ratio = 1.21, 95% confidence interval = 0.52-2.77).

CONCLUSION

Home-based primary and palliative care results in a high likelihood of nonhospital death, although certain demographic characteristics are strong predictors of death in the hospital. For MSVD participants, home visits in the last month of life were not associated with death outside the hospital.

Identifying Sociodemographic Characteristics Associated With Burden Among Caregivers of the Urban Homebound: The Importance of Racial and Relationship Differences

Limited research has explored whether the burden associated with caring for homebound patients varies across racial groups or by relationship status. We examined these variations for this vulnerable population. Patients self-identified informal caregivers and caregiver burden/depression were assessed using the Zarit Caregiver Burden Scale and the Center for Epidemiologic Studies–Depression scale (CES-D). Forty-nine informal caregivers completed the interview. Mean age was 58 (SD = 14), 78% were female, 37% Black, 35% Hispanic, and 46% had completed high school. Over 60% of caregivers had moderate or severe caregiver burden and 30% had significant depression. White caregivers had greater burden than Black and Hispanic caregivers (p = .02). Mean caregiver burden was higher among spouse/partner caregivers, versus those who identified as children or other family or friends (p = .004). Additional research is needed to better understand the experience of racial and ethnic minorities and spouses in providing informal care to homebound adults.

Reduction in symptoms for homebound patients receiving home-based primary and palliative care

BACKGROUND

Increasing numbers of patients are living with multiple, chronic medical conditions and functional impairments that leave them homebound. Home-based primary and palliative care (HBPC) programs provide access to health care services for this vulnerable population. Homebound patients have high symptom burden upon program enrollment. Yet little is known as to how individual symptoms are managed at home, especially over longer time periods.

OBJECTIVES

The purpose of this study was to determine whether high symptom burden decreases following HBPC enrollment.

METHODS

All patients newly enrolled in an HBPC program who reported at least one symptom on the Edmonton Symptom Assessment Scale (ESAS) were eligible for telephone ESAS follow-up. Patients received a comprehensive initial home visit and assessment by a physician with subsequent follow-up care, interdisciplinary care management including social work, and urgent in-home care as necessary. Multivariate linear mixed models with repeated measures were used to assess the impact of HBPC on pain, depression, anxiety, tiredness, and loss of appetite among patients with moderate to severe symptom levels at baseline.

RESULTS

One hundred forty patients were followed. Patient pain, anxiety, depression, and tiredness significantly decreased following intervention with symptom reductions seen at 3 weeks and maintained at 12 weeks. (p<0.01) Loss of appetite trended toward an overall significant decrease and showed significant reductions at 12 week follow-up.

CONCLUSION

In a chronically ill population of urban homebound, patient symptoms can be successfully managed in the home. Future work should continue to explore symptom assessment and management over time for the chronically ill homebound.

Symptom burden in chronically ill homebound individuals

OBJECTIVES

To document the degree of symptom burden in an urban homebound population.

DESIGN

Cross-sectional survey.

SETTING

The Mount Sinai Visiting Doctors (MSVD) program.

PARTICIPANTS

All individuals newly enrolled in the MSVD.

MEASUREMENTS

Edmonton Symptom Assessment Scale (ESAS), which consists of 10 visual analogue scales scored from 0 to 10; symptoms include pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, shortness of breath, and other.

RESULTS

ESAS scores were completed for 318 participants. Most participants were aged 80 and older (68%) and female (75%); 36% were white, 22% black, and 32% Hispanic. Forty-three percent had Medicaid, and 32% lived alone. Ninety-one percent required assistance with one or more activities of daily living, 45% had a Karnofsky Performance Scale score between 0 and 40 (unable to care for self), and 43% reported severe burden on one or more symptoms. The most commonly reported symptoms were loss of appetite, lack of well-being, tiredness, and pain; the symptoms with the highest scores were depression, pain, appetite, and shortness of breath. Participants were more likely to have severe symptom burden if they self-reported their ESAS, had chronic obstructive pulmonary disease or diabetes mellitus with end organ damage, or had a Charlson Comorbidity Index greater than 3 and less likely to have severe burden if they had dementia.

CONCLUSION

In chronically ill homebound adults, symptom burden is a serious problem that needs to be addressed alongside primary and specialty care needs.

A mobile medical care approach targeting underserved populations in post-Hurricane Katrina Mississippi

On August 29, 2005, Hurricane Katrina devastated the Gulf Coast Mississippi region, damaging health care infrastructure and adversely affecting the health of populations left behind. Operation Assist, a project of the Children's Health Fund and the Columbia University Mailman School of Public Health, operated mobile medical units to provide health services to underserved populations in the affected areas. Data collected from all patient encounters from September 5-20, 2005 demonstrate that in addition to common respiratory illnesses, skin conditions, and minor injuries, a high proportion of visits were for vaccine administration and chronic medical problems including hypertension, diabetes, and asthma. Mobile medical units staffed by primary care clinicians experienced in dealing with the clinical and social needs of the underserved and comfortable working in a resource-poor environment can make a positive contribution to post-disaster care.

Nondominant right coronary artery occlusion presenting with isolated right ventricular infarction and ventricular fibrillation

It is generally believed that serious complications are unlikely in a myocardial infarction resulting from occlusion of a nondominant right coronary artery. A case of isolated right ventricular infarction caused by total occlusion of a nondominant right coronary artery complicated by two episodes of ventricular fibrillation is presented.