POS0256 CLINICAL PREDICTORS OF ATTENUATED ANTIBODY RESPONSE TO PRIMARY SARS-CoV-2 VACCINATION IN A LARGE PROSPECTIVE STUDY OF PATIENTS WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES

Background

An attenuated humoral response to SARS-CoV-2 vaccination has been observed in some patients with rheumatic and musculoskeletal diseases (RMD) (1). We sought to identify clinical factors associated with poor humoral response following primary (two-dose mRNA or single adenoviral vector dose) SARS-COV-2 vaccination in patients with RMD on immunosuppression.

Objectives

To identify clinical predictors of an attenuated antibody response to primary SARS-CoV-2 vaccination in RMD patients on immunosuppression.

Methods

We included patients ≥18 years old with RMD on immunosuppression who received either two-dose mRNA or single dose Janssen/Johnson and Johnson (J&J) vaccination. Demographics, diagnoses, and therapeutic regimens were collected via participant report; those with prior COVID-19 infection were excluded. One month after vaccination, participants underwent SARS-CoV-2 antibody testing on the semi-quantitative Roche Elecsys anti-SARS-CoV-2 S enzyme immunoassay, which measures antibody to the SARS-CoV-2 S-receptor binding domain (RBD) protein (ceiling >250U/mL later expanded to >2500U/mL). Associations were evaluated using Fisher’s exact and Wilcoxon rank sum tests. Logistic regression analyses were performed to evaluate for clinical factors associated with antibody response. We adapted survival methods to address right-truncation of titers; this methodology was used to calculate medians. Participants provided informed consent electronically and the study was approved by the local Institutional Review Board.

Results

We studied 1138 RMD participants on immunosuppression; most were female (93%) and white (91%) (Table 1). One-hundred and fifteen (10%) had anti-RBD response in the negative range at a median (IQR) of 29 days (28-34) following completion of vaccine series. A greater proportion of participants with negative response were non-white, received J&J vaccine, reported use of mycophenolate, rituximab, or glucocorticoids. Antibody response differed by immunosuppressive regimen, with those receiving rituximab having poorest response (Figure 1). Use of mycophenolate (aOR 9.92, p=0.001), rituximab (aOR 56.99, p=0.001), glucocorticoids (aOR 2.99, p=0.001) or receipt of J&J (aOR 3.13, p=0.039) were associated with negative antibody response.

Table 1.

Clinical characteristics stratified by anti-SARS-CoV-2 RBD response

Negative (n=115)*Positive (n=1023)*p-value†Age,median(IQR)49(42, 58)47(37, 58)0.07Female sex,no.(%)108(94%)952(93%)0.78Non-white,no.(%)16(13.9%)83(8.1%)0.04Diagnosis,no.(%)Inflammatory arthritis22(19.1%)469(45.8%)<0.01SLE27(23.5%)193(18.9%)0.27Sjὅgren’s syndrome5(4.3%)46(4.5%)0.53Myositis13(11.3%)49(4.8%)<0.01Systemic sclerosis2(1.7%)9(0.9%)0.55Vasculitis12(10.4%)16(1.6%)<0.01Overlap connective tissue disease¶34(29.5%)24(23.6%)0.65  Vaccine,no.(%) Pfizer/BioNTech66(57.4%)548(53.6%)0.01Moderna38(33.0%)438(42.8%)J&J11(9.6%)37(3.6%)Non-biologic in regimen89(77.4%)725(70.9%)0.52Biologic in regimen84(73.0%)570(55.7%)0.01 Mycophenolate**56(48.7%)120(11.7%)<0.01 Rituximab54(47.0%)29(2.8%)<0.01 Glucocorticoid**61(53.0%)284(27.8%)<0.01Withheld immunosuppression18(21.2%)260(39.6%)<0.01

* Negative defined as anti-RBD titer <0.8 U/mL.

† Comparisons between negative and positive groups.

¶ Denotes a combination of two or more of the above conditions

** Mycophenolate: mycophenolic acid and mycophenolate mofetil. Corticosteroid: prednisone and prednisone equivalents

Figure 1.

Conclusion

Use of mycophenolate, glucocorticoids, rituximab and receipt of J&J vaccine were the strongest predictors of an attenuated antibody response to primary SARS-CoV-2 vaccination; these data support use of an additional primary dose in RMD patients.

References

[1]Deepak P, Kim W, Paley MA, et al. Effect of Immunosuppression on the Immunogenicity of mRNA Vaccines to SARS-CoV-2: A Prospective Cohort Study. Ann Intern Med. 2021.

Acknowledgements

We would like to acknowledge the contributions of: Brian J. Boyarsky MD, PhD, Jake A. Ruddy BS, and Jacqueline M. Garonzik-Wang MD PhD.

Disclosure of Interests

Caoilfhionn Connolly: None declared, Teresa Po-Yu Chiang: None declared, Mayan Teles: None declared, Sarah Frey: None declared, Jennifer Alejo: None declared, Allan Massie: None declared, Lisa Christopher Stine Consultant of: Janssen, Boehringer-Ingelheim, Mallinckrodt, EMD-Serono, Allogene, and ArgenX., William Werbel: None declared, Dorry Segev Speakers bureau: Sanofi, Novartis, CSL Behring, Jazz Pharmaceuticals, Veloxis, Mallincrodt, Thermo Fisher Scientific, Regeneron, and Astra-Zeneca, Consultant of: Sanofi, Novartis, CSL Behring, Jazz Pharmaceuticals, Veloxis, Mallincrodt, Thermo Fisher Scientific, Regeneron, and Astra-Zeneca, Julie Paik: None declared

Open inguinal hernia repair outcomes in liver transplant recipients versus patients with cirrhosis

PURPOSE

Patients with liver cirrhosis (LC) are at an increased risk for postoperative complications after open inguinal hernia repair (OIHR). It is possible that orthotopic liver transplant (OLT) recipients may have better outcomes, given reversal of liver failure pathophysiology. Therefore, we sought to compare mortality risk, complications, length of stay (LOS), and cost associated with OIHR in OLT recipients versus LC.

METHODS

From the National Inpatient Sample (NIS), using ICD-9 codes, we found 83 OLT recipients and 764 patients with LC who underwent OIHR between 2002 and 2014. We used logistic, negative binomial, and multiple linear regression models to compare peri-operative mortality risk, postoperative complications, and LOS, and cost associated with OIHR in OLT recipients versus LC patients. Models were adjusted for patient demographic and clinical characteristics, and hospital factors.

RESULTS

OLT recipients were younger (58 vs 61, p = 0.02), more likely to be privately insured (42.0% vs 24.6%, p = 0.006), less likely to have ascites at time of surgery (5.1% vs 18.9%, p = 0.003), and have surgery at large (84.3% vs 65.2%, p = 0.01) and teaching hospitals (84.2% vs 47.9%, p < 0.001). There were no mortalities among OLT recipients, but 19 (2.5%) deaths among LC patients. OLT recipients had a similar risk of overall complications (adjusted odds ratio aOR = 0.71 1.30 2.41) and hospital-associated costs (adjusted cost ratio = 0.71 0.88 1.09). However, LOS was significantly different with OLT recipients having shorter LOS (adjusted LOS ratio = 0.56 0.70 0.89).

CONCLUSION

Delaying OIHR in patients with LC until after OLT decreases LOS and may carry decreased mortality.

Urinary concentrations of organophosphate and carbamate pesticides in residents of a vegetarian community

Few population studies have measured urinary levels of pesticides in individuals with vegan, vegetarian, or organic diets. The objectives of this study were to evaluate whether a vegan/vegetarian diet was associated with increased exposure to organophosphate and carbamate pesticides, and to evaluate the impact of organic consumption on pesticide exposure in vegans and vegetarians. In the current pilot study conducted in 2013-2014, we collected spot urine samples and detailed 24h recall dietary data in 42 adult residents of Amirim, a vegetarian community in Northern Israel. We measured urinary levels of non-specific organophosphate pesticide metabolites (dialkylphosphates, (DAPs)) and specific metabolites of the current-use pesticides chlorpyrifos (3,5,6-trichloro-2-pyridinol (TCPy)), propoxur (-isopropoxyphenol (IPPX)), and carbaryl (1-naphthol). Six DAP metabolites were detected in between 67 and 100% of urine samples, with highest geometric mean concentrations for dimethylphosphate (19.2μg/g). Creatinine-adjusted median concentrations of total DAPs and of TCPy were significantly higher in Amirim residents compared to the general Jewish population in Israel (0.29μmol/g compared to 0.16, p<0.05 for DAPs and 4.32μg/g compared to 2.34μg/g, p<0.05 for TCPy). Within Amirim residents, we observed a positive association between vegetable intake and urinary TCPy levels (rho=0.47, p<0.05) and lower median total dimethyl phosphate levels in individuals reporting that >25% of the produce they consume is organic (0.065μmol/L compared to 0.22, p<0.05). Results from this pilot study indicate relatively high levels of urinary organophosphate pesticide metabolite concentrations in residents of a vegetarian community, a positive association between vegetable intake and urinary levels of a chlorpyrifos specific metabolite, and lower levels of total dimethyl phosphate in individuals reporting higher intake of organic produce. Results suggest that consumption of organic produce may offer some protection from increased exposure to organophosphate pesticide residues in vegetarians.

Design of shallow donor levels in diamond by isovalent-donor coupling

Using the first-principles pseudopotential method, we have studied simultaneous isovalent and n-type doping in diamond. We show that Si induces fully occupied isovalent levels near the valence band maximum. The Si levels interact with N donor levels, making them much shallower. The donor transition energy level of the N + 4Si defect complexes is found to be 0.09 eV below the conduction band minimum, which is the shallowest level found thus far for this system. The binding energy of the N + 4Si complex is also large enough to insure its stability.

Methylene blue, a nitric oxide inhibitor, prevents haemodialysis hypotension

BACKGROUND

Plasma nitric oxide (NO) levels have been found to be high in haemodialysis (HD) patients, especially in those prone to hypotension in dialysis. The aim of the study was to prevent dialysis hypotension episodes by i.v. administration of methylene blue (MB), an inhibitor of NO activity and/or production.

METHODS

MB was given i.v. in 18 stable HD patients with hypotensive episodes during almost every dialysis, in 18 HD patients without hypotension during dialyses, and in five healthy controls. MB was given as a bolus of 1 mg/kg bodyweight followed by a constant infusion of 0.1 mg/kg bodyweight lasting 210 min until the end of the dialysis session and only as a bolus on a non-dialysis day. Systolic and diastolic blood pressures (BP) were measured at 10-min intervals during HD sessions with or without MB and on a non-dialysis day with MB.

RESULTS

In hypotension-prone patients, MB completely prevented the hypotension during dialysis and increased both systolic and diastolic BP on non-dialysis days. In normotensive patients, MB increased BP during the first hour of dialysis and for 90 min on the non-dialysis day. The BP in the healthy controls remained unchanged. Plasma and platelet NO(2)+NO(3) (stable metabolites of NO) levels were determined. The NO(2)+NO(3) generation rate in the first post-dialysis day was calculated. The plasma and platelet NO(2)+NO(3) were higher in the hypotensive group than in the normotensive dialysis group. The generation rate of nitrates was higher (P<0.01) in the hypotensive group (1.21+/-0.13 micromol/min and 0.74+/-0.16 after MB) than in the normotensive patients (0.61+/-0.11 micromol/ min and 0.27+/-0.14 after MB). No side-effects were recorded.

CONCLUSIONS

MB is an efficient therapy in the prevention of dialysis hypotension.

Kerosene-induced severe acute respiratory failure in near drowning: reports on four cases and review of the literature

OBJECTIVE

The purpose of this study is to present an unusual respiratory and cardiovascular course after intoxication and near drowning in a river contaminated with kerosene.

DESIGN

Case reports and review of the literature.

SETTING

Intensive care unit of a university-affiliated hospital.

PATIENTS

Four patients after near drowning.

INTERVENTION

Supportive only.

RESULTS

The four patients developed acute respiratory failure. Cardiomyopathy was present in three patients and a persistent hypokalemia in two patients. The onset of the symptoms was delayed, which led to underestimation of the severity of their illness. Two of the four patients died. The diagnosis of hydrocarbon intoxication was based on bronchoalveolar lavage results, neutrophilic alveolitis with the presence of lipid-laden macrophages, and evidence of lipoid pneumonia from the autopsy performed on one victim. One patient who clinically deteriorated and another who developed a severe restrictive pulmonary disorder were treated with corticosteroids, which were effective only in the latter patient.

CONCLUSIONS

Acute kerosene intoxication in a near-drowning event often results in severe respiratory and cardiac failure, with a high fatality rate. Treatment with corticosteroids may lead to a rapid improvement in lung function.

Absence of activating mutations of the genes encoding the alpha-subunits of G11 and Gq in thyroid neoplasia

Activating mutations of the TSH receptor and alpha-subunit of Gs (G alpha s) that increase adenylyl cyclase activity have been identified in a subset of hyperfunctioning benign thyroid follicular adenomas and, less commonly, in hypofunctioning adenomas and carcinomas. In addition some thyroid tumors exhibit inappropriate activation of phospholipase C (PLC), a signaling pathway that has been implicated in the growth and dedifferentiation of thyroid cells. We therefore hypothesized that some thyroid tumors might be caused by somatic mutations in the genes encoding the alpha-chain of Gq or G11 that result in constitutive activation of the PLC pathway. We amplified regions of the alpha q and alpha 11 genes that encode amino acids, Q209 and R183, and we screened the DNA for mutations by sequence analysis and denaturing gradient gel electrophoresis. No mutations were identified after analysis of DNA from 38 thyroid tumors and 2 poorly differentiated thyroid carcinoma cell lines, including: 13 follicular adenomas, 10 follicular carcinomas, 5 papillary carcinomas, and 10 hyperplastic nodules from multinodular goiters. We conclude that activating mutations of alpha q and alpha 11 are absent or rare in hypofunctioning thyroid neoplasms and that other mechanisms must explain the elevated PLC activity reported in thyroid carcinoma.

Very early onset of acute amiodarone pulmonary toxicity presenting with hemoptysis

A case of amiodarone pulmonary toxicity (APT) occurring within days of the start of therapy and presenting with hemoptysis is reported. Both the very early onset and the presenting symptom are highly unusual in this entity. Implications in the diagnosis of APT are discussed.

Initial experience with FK506 (tacrolimus) in pediatric renal transplant recipients

PURPOSE

The efficacy and safety of the new immunosuppressant agent, FK506 (tacrolimus), was assessed in pediatric renal transplant recipients over a mean 12-month follow-up period.

METHODS

Twenty pediatric renal transplant recipients received oral FK506 therapy (0.3 mg/kg/d) in combination with azathioprine (1 to 2 mg/kg/d) and low-dose prednisone as primary therapy (n = 11) or were converted from cyclosporine-based therapy (n = 9) for complications including cyclosporine toxicity (n = 2), acute refractory rejection (n = 4), and chronic rejection (n = 3). Patients were then followed-up prospectively to evaluate effectiveness of therapy and complications.

RESULTS

In the primary treatment group, 45% of patients had one or more rejection episodes. Two required OKT3 therapy (18%) for persistent rejection, with one (9%) graft loss at 3 months. All other episodes were treated effectively with FK506 dose adjustment and steroid pulses. Patient and graft survival was 100% and 91%, respectively, at 12 months mean follow-up. In the FK506 conversion group, two teenage girls with intractable acne and hirsutism were converted with complete resolution and no change in renal function. Four patients were converted for acute rejection: two who did not respond to steroid pulse and two who did not respond to both steroids and OKT3. All four grafts were salvaged (mean follow-up, 12 months; mean Creatinine [Cr], 1.1). Three patients were converted for biopsy-proven chronic rejection at 3, 10, and 12 years after transplant (mean Cr, 2.4) with two of three of patients stable with functioning grafts at 1 year after conversion. Complications of FK506 therapy included temporary insulin-dependent diabetes mellitus (10%), neurological complications (25%), renal toxicity (15%), and hypertension (85%). There were no cases of gastrointestinal toxicity, hepatic dysfunction, lymphoproliferative disorders, or life threatening viral infection. All symptoms of toxicity responded to dose adjustment. No patient required conversion from FK506 to other agents.

CONCLUSION

This early experience indicates that FK506 in combination with low-dose steroids and azathioprine appears to provide safe and effective immunosuppression in the pediatric age group as a primary agent and may salvage grafts in patients with refractory steroid and OKT3 resistant rejection. Graft and patient survival is comparable to that seen with conventional cyclosporine-based immunosuppression.

Efficient constitutive production of human IFN-gamma in Chinese hamster ovary cells

A human genomic DNA segment of 5.6 kb containing the entire gene for immune interferon-gamma was fused through its 5'-untranslated region to the corresponding region of the simian virus 40 (SV40) T-antigen gene. The SV40 early promoter used contained a modified transcriptional enhancer element with a 93-bp repeat. Supercoiled plasmid DNA was used to transfect Chinese hamster ovary (CHO) cells, the selectable marker being a SV40-dihydrofolate gene construct. Constitutive expression of the IFN-gamma gene in primary transformants was high, especially if a Harvey murine sarcoma virus long terminal repeat (LTR) was present in addition to the SV40 promoter. After gene amplification by methotrexate selection, CHO-gamma cell lines were obtained that produce 1.5-2 million units of IFN-gamma per million cells and per day (200,000 molecules per cell per minute). Metabolic labeling showed that over 90% of the protein secreted by such cells is human IFN-gamma. A one-step immuno-affinity chromatography on monoclonal antibodies yielded pure IFN-gamma with 1-2 X 10(8) units/mg protein. Like IFN-gamma from human white blood cells, the IFN-gamma from CHO-gamma cells is a mixture of two glycoproteins of 26,000 and 20,000 daltons with traces of the unglycosylated 17,000-dalton polypeptide. Large-scale cultures in 1% serum routinely yield over 600,000 units of human IFN-gamma/ml culture per day.

Detection of avocado sunblotch viroid by hybridization with synthetic oligonucleotide probes

Two short (20 and 17 nucleotides) DNA hybridization probes, complementary to avocado sunblotch viroid (ASBV) RNA nucleotides 68-87 and 88-104 respectively (Symons, R.H., Nucleic Acid Res. 9, 6527, 1981) were synthesized. The sensitivity and specificity of these radioactively labelled probes for hybridization with RNA of several ASBV isolates are demonstrated.

Displacement potency of vitamin D2 analogs in competitive protein-binding assays for 25-hydroxyvitamin D3, 24,25-dihydroxyvitamin D3, and 1,25-dihydroxyvitamin D3

24(R),25-Dihydroxyergocalciferol [24,25-(OH)2-D2] is 1.7 times less potent than 24 (R), 25-(OH)2D3, 25-Hydroxyvitamin D2 (25OHD2), or 25OHD3 in the displacement of (3H)25OHD3 from rat serum binding proteins. 1,25-(OH)2D2 is 1.3 times less potent than 1,25-(OH)2D3 in the displacement of (3H)1,25-(OH)2D3 from a chick intestinal binding receptor. In light of binding affinity and chromatographic differences between vitamin D3 and its D2 analogs, it is our view that methods which purport to measure 1,25-(OH)2D and 24,25-(OH)2D probably understimate the contributions of D2 metabolites. This is particularly important in the case of plasma extracts from patients given large doses of vitamin D2.